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81 Cards in this Set
- Front
- Back
Psychosocial History
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Perception of own health, beliefs about illness+wellness
Activity/leisure activities, how PT passes time, use/abuse substances, stress level+ coping abilities+strategies+support systems, culture, spiritual |
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5 Levels of consciousness
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Alert, lethargy, obtundation, stupor, coma
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Alert
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PT is responsive and able to fully respond by opening eyes+attending to a normal tone of voice and speech. She answers questions spontaneously + appropriately.
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Lethargy
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PT is able to open eyes and respond but is drowsy and falls asleep readily
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Obtundation
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PT needs to be lightly shaken to elicit response, but she may be confused and slow to respond
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Stupor
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PT requires painful stimuli (pinching tendon or rubbing sternum) to elicit a brief response. She may not be able to respond verbally.
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Coma
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No response can be achieved from repeated painful stimuli.
-Abnormal posturing in PT who is comatose -Decorticate rigidity: flexion+internal rotation of upper-extremity joints and legs Decerebrate rigidity: neck+elbow extension, wrist and finger flexion |
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Decorticate Rigidity
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Flexion + internal rotation of upper-extremity joints and legs
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Decerebrate rigidity
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Neck + elbow extension, wrist and finger flexion
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Physical Appearance
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Exam includes: assess person hygeine, grooming, and clothing choice. Expected findings = PT well kept, clean, dressed appropriately for given environment
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Behavior
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Exan includes assess of voluntary + involuntary body movements and eye contact
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Mood
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Mood provides info about emotion that PT is feeling
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Affect
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An objective expression of mod, such as flat affect or lack of facial expression
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Recent Memory
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Ask PT to repeat series of numbers or a list of objects
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Remote
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Ask PT to state a fact that is verifiable, (birth date, mother's maiden name)
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Assessing Speech
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Assess rate and volume, + quality of his language. His speech should be articulate and his responses meaningful and appropriate.
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Assessing Judgement
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Based on answer to hypothetical question - "what would you do if there were a fire in your room?" Response to question should be logical.
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Mini Mental State Examination (4)
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1. Orientation to time and place
2. Attention span + ability to calculate by counting backward by seven 3. Registration and recalling of objects 4. Language, including naming of objects, following of commands, and ability to write |
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Glasgow Coma Scale
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Used to obtain baseline assessment of Pt's level of consciousness, and for ongoing assessment. Eye, verbal, and motor response is evaluated. Number value based on response is assigned. Highest value = 15. Score of 3 indicates that the client is in a coma.
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Mentally Healthy Children + Adolescents
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Should trust others, view world as safe, accurately interpret environment, master developmental tasks, and use appropriate coping skills
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Mental health + development disorders are not always easily diagnosed b/c....
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Lack of ability/necessary skills to describe what is happening
A wide variation of "normal" behavior, especially in different developmental stages |
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Assess children + adolescents for..
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mood, anxiety, developmental, behavioral, and eating disorders. Risk of suicide should also be considered.
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Other things included in older adult assessment (4)
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1. Functional ability - like ability to get up out of chair
2.Economic + social status 3. Environmental factors, such as stairways in the home, that may affect the PT's well-being and lifestyle 4. Physical assessment |
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Standardized Assessment Tolls that are specific to the older population: (4)
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1. Geriatric Depression Scale (short form)
2. Michigan Alcoholism Screening Test (geriatric version) 3. Mini Mental Status Exam 4. Pain assessments including visual analogue scales, wong-baker FACES Pain Rating Scale, the McGill Pain Questionnaire, Pain Assessment in Advanced Dementia |
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The DSM-IV-TR
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Uses a multiaxial system to assess PTs in mental health setting. It assesses for abnormal behavior, comorbid mental conditions, conditions within the environment, and level of functioning
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Axis I
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All mental health diagnosis except for thouse found in Axis II
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Axis II
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Any personality disorder diagnosis and mental retardation
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Axis III
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Any general medical diagnosis, such as asthma
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Axis VI
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Pertinent psychosocial problems and problems that may affect diagnosis, treatment and prognosis of mental disorders
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Axis V
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Global assessment of functioning - assessment of present + past year functioning that rates PT's level of functioning in the areas of work performance, social abilities, and psychological ability on a scale 1-100
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Global Assessment of Function (GAF) score 80-100
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generally indicate normal or near-normal function
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Global Assessment of Function (GAF) score 60-80
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Indicates moderate problems
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Global Assessment of Function (GAF) score 40 or below
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Serious mental disability and/or functioning impairments
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Counseling
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Uses therapeutic communication skills, assisting with problem solving, crisis intervention, stress management
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Milieu Therapy
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Orienting client to physical settinging, identifying rules and boundaries of the setting, ensuring a safe environment for client, assisting the client to participate in appropriate activites
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Promote of self-care activites
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Offering assistance w/self-care tasks, allowing time for the client to complete self-care tasks
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Psychobiological Interventions
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Administering prescribed medications, providing teaching to pt/family, monitoring for side effects and effectiveness of therapy
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Cognitive and Behavioral Therapies
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Modeling, operant conditioning, systematic desensitization
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Health Teaching
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Teaching social and coping skills
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Health Promotion and Health Maintenance
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Assisting the client with cessation of smoking, monitoring other health conditions
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Case Management
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Coordinating holistic care to include medical, mental health, and social services
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Beneficence
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Relates to quality of doing good/can be described as charity
ex: nurse helps new client w/psychosis feel safe in environment of facility |
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Autonomy
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PT's right to make his own decisions. But PT must accept the consequences of those decisions. PT must also respect the decisions of others.
ex:Rather than giving advice to a PT who has difficult making decision, as nurse helps the PT explore all alternatives and arrive at a choice. |
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Justice
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This is defined as fair and equal treatment for all.
During treatment team meeting - nurse leads a discussion regarding whether or not 2 PTs who broke the same facilitiy rule were treated equally. |
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Fidelity
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R/t loyaly and faithfulness to PT and one's duty
PT asks nurse to be present when she talks to her mom for the 1st time in a year. Nurse remains w/client during this interaction |
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Veracity
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This refers to being honest when dealing with a client.
ex: Pt says you and other staff member were talking about me, weren't you? - RN replies truthfully - we were discussing ways to help you relate to the other PTs in a more positive way |
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Voluntary Commitment
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PT or guardian chooses commitment to a mental health facility in order to obtain treatment. A voluntary committed client has the right to apply for release at any time. PT considered competent, and has the right to refuse medication and treatment.
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Involuntary (civil) Commitment
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PT enters the mental health facility against her will for an indefinite period of time. Commitment is based on the PT's need for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care. The need for commitment could be determined by a judge of the court or by another agency. The number of physicians - usually 2 - required to certify that the PTs condition requires commitment, varies from state to state.
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Emergency Involuntary Commitment
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Type of involuntary commitment in which PT is hospitalized to prevent harm to self or others. Emegerncy commitment is usually temporary (may be up to 10 days). This type of commitment is usually imposed by PCPs, mental health providers, or police officers.
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Observation/temporary involuntary Commitment
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PT is in need of observation, a diagnosis, and a treatment plan. The time for this type is controlled by state statue and varies greatly btw states. This may be imposed by a family member, legal guardian, PCP, or mental health provider.
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Long-term of formal involuntary Commitment
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Similar to temporary commitment but must be imposed by the courts. Time of commitment varies, but is usually 60-180 days. Sometimes there is no set release dates.
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PTs admitted under involuntary commitment
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Still considered competent and have right to refuse treatment, unless gone thru legal competency hearing and have been judged incompetent. PT who has been judged incompentent has temporary or permanent guardian, usually a family member if possible - appointed by the court. The guardian can sign informed consent for the client. The guardian is expected to consider what the client would want if he were still competent.
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Seclusion and/or restraint must never be used for:
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1. Convenience of the staff
2. Punishment of PT 3. PTs who are extremely physically or mentally unstable 4. PTs who cannot tolerate the decreased stimulation of a seclusion room |
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Following must occur in order for seclusion or restraint to be used:
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1. Treatment must be orderd by PCP in WRITING
2. Order must specify duration of treatment Provider must rewrite order, specifying type of restraint, q 24 hrs or the frequency of time specified by facility policy |
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In order for restraints - nursing responsibilities must be identified in protocol, including how often the PT should be:
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1. assessed (safety/physical needs), and PT's behavior documented
2. Offered food+fluid 3. Toileted 4. Monitored for VS |
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Complete documentation of use of restraints includes:
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precipitating events and behavior of the PT prior to seclusion or restraint
Alernative actions taken to avoid seclusion/restraint Time treatment began PT's current behavior, what foods or fluids were offered and taken, needs provided for and VS Medication administration |
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Emergency situation + restraints/seclusion
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An ER situation must be present for charge nurse to use seclusion or restraints w/out first obtaining a provider's written order. If treatment is intiated - nurse must obtain written order w/in a specified period of time (usually 15-30 min)
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Tort: False Imprisonment
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Confining PT to specific area, such as seclusion room, is false imprisonment if the reason for such confinement is for the convenience of the staff.
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Assault
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Making a threat to a PT's person, such as approaching PT in a threatening manner w/a syringe in hand, is considered assault
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Battery
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Touching a client in a harmful or offensive way is considered battery. This would occur if the nurse threatening the client with a syringe actually grabbed the PT and gave the injection.
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3 Levels of Basic Communication
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Intrapersonal
Interpersonal Public Transpersonal |
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Intrapersonal Communication
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Communication that occures w/in an individual. Also identified as "self-talk". This occurs within one's self and is the internal discussion that takes place when an individual is thinking thoughts and not outwardly verbalizing them. In nursing - it allows the nurse to assess a pt AND/OR SITUATION AND CRICIALLY THINKING ABOUT THE PT before communicating verbally
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Interpersonal Communication
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Communication that occures betwen 2 or more ppl in a small group. This form is the most common in nursing and requires an exchange of info w/an individual or small group.
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Public Communication
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Communication that occurs w/in large groups of people. In nursing - this commonly occurs during educational endeavors where the nurse is teaching a large group of individuals - community setting.
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Transpersonal Communication
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Addresses an individual's spiritual needs and provides interventions to meet those needs.
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Verbal Communication/ Content of the message:
Denotative/Conotative Meeting - when communicating, participants must share meanings |
Words that have multiple meanings may cause miscommunication if they are interpreted differently
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Verbal Communication/ Content of the message:
Clarity/Brevity: shortness, simplest communication is usally most effect |
Communication that is long and complex may be difficult to understand
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Verbal Communication/ Content of the message:
Timing/Revelance: Knowing when to communicate allows the receiver to be more attentive to the message |
Communicating w/a PT who is in pain or distracted will make it difficult for the message to be conveyed
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Verbal Communication/ Content of the message:
Pacing - the rate of speech can communicate a meaning to the receiver |
Speaking rapidly may communicate the impression that the nurse is in a rush and does not have time for PT
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Verbal Communication/ Content of the message:
Intonation - tone of voice can communicate variety of feelings |
RN can communicate feelings, such as acceptance, judgment, and dislike thru tone of voice.
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Nonverbal Communication
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Appearance, posture, gait, facial expression, eye contact, gestures, sounds, territoriality, personal space, silence
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Characteristics of Therapeutic Communication
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Client centered - not social or reciprocal
Purposeful, planned, and goal directed |
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Essential Components of Therapeutic Communication
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-Time (allow for enough)
-Attending behaviors -Eye contact -Body language/posture Vocal quality Verbal tracking (provides feedback by restating or summarizing a pt's statements) Caring attitude Honesty Trust Empathy Nonjudgemental attitude |
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Empathy
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Convery an objective awareness and understanding of the feelings, emotions, and behaviors of others - including trying to envision what it must be like to be in the position of the PT and Pt's family
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Communication w/Children
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-Use simple, straightforward language
-Be aware of own nonverbal messages - children sensitive to nonverbal communication -Enhance communication by being at the child's eye level - Incorporate play in interactions |
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Communication w/Older Adults
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-Recognize that PT may require amplification
-Minimize distractions, and face the PT when speaking -Allow plenty of time for the PT to respond -When impaired communication is assessed, ask for input from caregivers or family to determine the extent of the defecits and how best to communicate |
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Communication - Planning
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Minimize distractions, provide for privacy, identify mutually agreed-upon client outcomes, set priorities according to the PT's needs, plan for adequate time for interventions
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Clarifying techniques
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Restating
Reflecting Paraphrasing Exploring |
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Offering Self
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Demonstrates willingness to spend time w/PT. Limited personal info shared. Relevant self-disclosure by the nurse allows the PT to see that his experience is shared by others and understood
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Touch
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Only if appropriate - provides comfort to PT
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Barriers to Effective Communication
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Asking irrelevant personal q's
Offering personal opinions Giving advice Giving false reassurance Minimize feelings Changing topic Ask "why" questions Offering value judgements Excessive questioning Responding approvingly or disapprovingly |