Ati Fundamentals

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Three Primary levels of communication

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Intrapersonal, Interpersonal, Public

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Referent

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The incentive or motivation for communication to occur between one person and another

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Sender

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THE PERSON WHO INITIATES THE MESSAGE

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Message

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The verbal or nonverbal information that is expressed by the sender and intended for the reciever

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Channel

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The method of transmitting and recieving a message (recieved via sight, hearing, and or touch)

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Reciever

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The person to whom the message is aimed

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Environment

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the emotional and physical climate in which the communication takes place

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Feedback

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May be verbal and or non verbal, positive and or negative.
The message that is returned to the sender by the reciever that indiacates the message has been recieved.
An essential component for ngoing communication

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Vocabulary

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Use of medical jargon such as "Decubitus ulcer".

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Connotative meaning

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Charting that is written"client complains of" vs "Client reports"

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Pacing (miscommunication of)

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A client not asking the nurse a question because the nurse is talking rapidly and seems very busy

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Clarity (miscomminication of)

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A nurse distractingly using the phrase "um" repetitively in her communication

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Timing (miscommunication of)

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A nurse attempting to teach a client about her medications while the cleint is waiting for a phone call from her granddaughter

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Nurse says "turn to your side now honey" Nurse believes calling client honey is caring, client doesnt like it....what is the cause of this miscommunication

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Connotative meaning of the word honey is different for nurse and client

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Vocabulary

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words that are used to communicate

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Denotative/connotative meaning

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When communicating. the meanings that are shared. Shared words that have different meanings may cause miscommunication when interpreted differently

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Nonverbal communication

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Appearance
Posture
Gait
Facial expressions
Eye contact
Gestures
Sounds
Territoriality
Personal Space

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Techniques that enhance Communication

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Active listening
Silence
Giving Info,
Sharing empathy, hope, humor, + feelings,
Focusing,
Reflecting and clarifying,
Paraphrasing and restating

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Techniques that hinder Communication

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Stereotyping,
Challenging,
Arguing,
Giving unwarranted reassurance,
Giving Advice,
judgmental or defensive responses,
Ignoring feelings,
Not listening

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Therapeutic communication

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purposefull communication to build and maintain helping relationships

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Phases of therapeutic communication

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Orientation
Working
Termination

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Characteristics of therapeutic communication

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Purposefull, Planned, Goal-directed

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Orientation Phase of therapeutic Communication

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establishes the purpose of the relationship and the time frame available for work to be done. It is the intial contact

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Working phase of therapeutic communication

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Sets goals and works toward meetinf them

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Termination Phase

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evaluates what has been accomplished and brings the relationship to close.

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Essential components of therapeutic communication

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Caring attitude, Honesty, Trust, Empathy, Nonjudgemental attitude,

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An adelescent is admitted to er with fever, the pt is withdrawn and tearful. What is an example of therapeutic communication?

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Nurse says, " You Look frightened"

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A nurse reckognizes that a helping relationship is established with a client if the communication

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encourages the client to express his thoughts and feelings

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When communicating with a child who is seated, the nurse should

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sit at eye level with the child

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Behaviors of active listening

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Maintaining an open posture
Establishing and maintaining eye contact,
Responding positively when giving feedback

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which statement does not block communication? "You have taked alot about your symptoms of hyperkalemia, but lets discuss the trouble you are having with your potassium supplement" or "Why are you not taking your potasium supplement?"

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"You have taked alot of your symptoms".......
Try to avoid Why questions

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Which statement does not block communication "When did you last take your phenytoin?" or " You should have taken your phenytoin this morning before breakfast, Did you?"

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"When did you last take...."
"You shd have" is an pinionated statement

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Information to be charted includes

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Assesments
Medication administration,
Treatments given and client responses, Client education

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How do you document subjective data

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Can be documented as direct quotes, within quotation marks, or summarized and identified as the clients statement

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How do you document objective data

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should be descriptive and should include things that the nurse sees, hears, feels, and smells. Leave out derogatory words, judgement, or opinion. be accurate, instead of "client is agitaed' write " client pacing back and forth inhes room, yelling loudly"

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What information should be included in the tranfer paperwork when an elderly client is being transfered from accute care facility to a long term care facility

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State the clients name, age,medical diagnosis, nursing care plan, diet and activity parameters, family, support system, allergies, current medsand advance directives

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PRIOR TO TRANSFERING A CLIENT, HIS neighbor CALLS TO ASK WHERE THE CLIENT IS BEING TRANSFERED, How should the nurse respond?

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Explain to the nieghbor that the information is confidentual and that he must contact the clients family

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The nursing care provided is recorded as

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documentation and charting

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The clients chart or medical record is the

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legal record of care

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The clients chart is

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confidential, permanent and legal document admissable in court

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Information to be charted is

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Assesmnets, Medication administration, treatments given and client responces, client education

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Subjective Data

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documented as direct quotes, withen quotation marks or summarized and identified as the clients statement

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Objective data

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descriptive. Things the nurse shes hears feels or smells. document w/o judgement stating opinion.

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Legal guidelines for documentation

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begin each entry with date and time, record in black ink, do not leave blank spaces,do not use correction fluid or blacken out errors. signed with signature and title

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flow charts

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record vital signs, blood glucose levels, pain level,and other assesments that are preformed frequently in order to show trends

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Narrative

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records information in a sequence of events

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Charting by exception

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Standardized forms that identify normal findings/values and allows for selective documentationof abnormal findings

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Problem orientated medical records

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consists of a data base, problem list, care plan, and progress notes

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Various formats for completing progress notes

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Soape, Pie, Dar

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Soape

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Subjective data
Objective data
Assesment + nursing diagnosis
Plan
Evaluation

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Pie

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Problem
Intervention
Evaluation

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Transfer reports should include

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Client demographic information
Summary of progress up to transfer
Current health statous (physical and psychosocial)
Critical assesments
Current Nursing diagnosis + care plan
Medications and dosages
Allegies
Diet and activity orders
Advance directives
Family support
Special equiptment needed (o2,suction, wheelchair)

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Incident reports

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Any occurance that is inconsistant with the clients routine car should be reported ex. med. errors, falls, needle sticks