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115 Cards in this Set

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What is he purpose of Written communication/ documentation.
Serves as a permanent record of client information.
What are the two categories for communication in the nursing process.
Written and Verbally.
When does reporting take place.
When two or more people share information about client care.
In what ways can verbal reporting take place.
1. Face to Face (team meeting or handoff or shift report.
2. Audio tape: Voice mail
3. Telephone (reports to case manager or physician)
What must be accessible to member of the healthcare team who care for a client
Accurate and complete data on the client.
What information is essential when charting.
-any new or change information
-signs & symptoms
-client behaviors
-nursing interventions
-medications given
-physician's orders carried out
-client teaching
-client responses
-any change in the care plan
What information should the client's record contain.
-Assessment
-Care planning
-communication (the plan of care and the client's progress to all members of the health care team)
-Education
-Reimbursement (documentation of client care to provide basis for decision making regarding compensation)
-Research
-Quality Assurance (Audit is a review of records and serve: quality assurance and reimbursement)
What should you do if you make a mistake on a patient's chart.
put a line through the error and initial it.

Some health care setting may require you to write explanation of what error was.

NEVER ERASE ANYTHING
What are the principles of good documentation.
-Conciseness (brief and to the point)
-Objectivity
-Organization (Chronological flow of info. according to time procedures completed with client's reactions documented. Helps prevent out of sequence or fragmented data)
-Timeliness
-Legibility
What is the purpose of Universal Computer Based Patient Records.
Allows clients to share health information with any practitioner regardless of institutional affiliation or time and place when care was originally provided.
What is Point of Care Documentation.
Documentation that takes place as care occurs.
What is the goal of point of care documentation.
To promote efficiency, accuracy and timeliness.
Three Standardized Vocabulary Nursing & Medical Databases used are?
NIC - Nursing Intervention Classification
NOC - Nursing Outcome Classification
NANDA - North American Nursing Diagnosis Association.
What is nursing informatics?
A combination of computer science, information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care.
When should a plan of care be generated and revised.
Should be generated at admission and revised to reflect changes in the client's condition.
What is a Kardex
Information on the patient. It is usually kept in a portable file at the nurses station.
Information Found on a Kardex
Demographic - (name, age, occupation, religion, physician, dx)
Basic Needs - (diet, activity, hygiene, safety precautions)
Allergies
Diagnostic Tests
Daily Nursing Procedures - (dressing changes, VS)
Therapies - (respiratory, etc.)
The purpose of a Kardex
A way to ensure continuity of care from one shift to another.
Four types of Nursing Notes
Narrative Notes
SOAP Notes
PIE Notes
Focus DAR Notes
Narrative Notes
Information provided in written sentences or phrases; usually time sequenced.
Advantages of Narrative Notes
Easy to learn; easy to adjust length as needed; can be explained in detail
Disadvantages of Narrative Notes
Time consuming; difficult to retrieve information; irrelevant information ofter included; possibly unfocused and disorganized.
SOAP Notes
Progress note that relates to only one health problem

S- Subject data O- Objective data A - Assessment P- Plan
Advantages of SOAP Notes
All charting focuses on identified client problems; interdisciplinary - all team members chart on the same progress notes; easy to track progress for identified problems; steps in the nursing process are mirrored.
Disadvantages of Soap Notes
Difficult to master; specific focus makes it difficult to chart general information without identifying a problems; lengthy and time consuming
PIE Notes
Documentation is entered for each nursing diagnosis.

P - Problem I- Intervention E-Evaluations
Advantages of PIE Notes
Plan of care incorporated into progress notes; outcomes included; daily review to determine progress
Disadvantages of PIE Notes
Must read progress notes to determine plan of care; If problem has not been identified, difficult to chart; not multidisciplinary
Focus DAR Notes
D- Data
A-Action
R-Response
Advantages of Focus DAR Notes
Broad view permitting charting on any significant area, not just problems
Disadvantages of Focus DAR Notes
Not multidisciplinary; difficult to identify chronological order; progress notes may not relate to care plan
Flowsheets
Document routine nursing procedures such as VS, intake and output.
Charting by Exception (CBE)
Documents only those findings that fall outside the standard of care.
Clinical Pathways
Serve a multidisciplinary tools, identifying the expected progression of the client toward discharge. They provide direction about major interventions to be performed: Assessments, diagnostic tests, procedures, medications, teaching, activity, diet and discharge planning.
Documentation occur on the pathway form and usually the nurse is required to sign his or her initials when a specific intervention has occurred or been met.
Information provided during Nurse to Nurse Oral Communication? Continuity between Shifts or Client Visits.
-Name, age, room # of client
-Medical diagnoses, major procedures or surgery
-Physician name or group
-Significant assessment findings, including VS
-Diagnostic and laboratory test results
-Specific treatments (i.e. dressing changes, respiratory therapy)
Nursing Rounds
Walking rounds where nurses visit a group of clients, and the nurse assigned to each client summarizes the client's current status and plan or care.
When is a report prompted to the Primary Care Provider.
Prompted by a change in the client's condition.
Outcomes of Communication
-Nurse and client solve healthcare problems together
-client cared for and understood
-family/significant other included in care
-health teaching concluded
-health promotion and prevention care are delivered
What does verbal communication involve
Involves the spoken or written word (i.e. TV, movies, books, computers)
What does non verbal communication involve.
gestures, facial expressions, posture, body movements, voice tone and volume, rate of speech and even dress.
Congruent Relationships
Nurses thoughts and feelings that match his or her expressions.
Incongruent Relationships
Nurses thoughts and feelings do not match his or her expressions.
Sender factors that interfere with the encoding process.
-unclear speech
-monotone voice
-poor sentence structure
-inappropriate use of terminology or jargon
-lack of knowledge about the topic
Receiver factors that interfere with the encoding process
-lack of attention
-prejudice or bias
-preoccupation with another problem
-physical factors such as pain, drowsiness, or impairment of the senses
What are the phases of the nurse-client relationship.
Orientation
Working
Termination
Oriention Phase Of Nurse-Client Relationship
Consist of introductions and an agreement between nurse and client about their mutual roles and responsibility.

The nurse and client get to know each other and develop trust and rapport.
Working Phase of Nurse-Client Relationship
Nurse and client participate together in nursing care activities.
Termination Phase fo Nurse-Client Relationship
Closure of the relationship and discharge planning.
Elements of the Nurse Client Relationship.
-Nurse and client knows each other names
-Roles and responsibilities clarified
-Parameters of the professional relationship are clear
-Mutual expectation agreed on
-Advocacy -being an advocate for the client's right to info. necessary to make decisions about treatment options and care
-Circle of confidentiality respected.
Guidelines for facilitating communication
-speak in normal tone of voice
--speak to client on adult level
-avoid engaging in multiple conversations at same time
-ask simple question that require simple answers
-keep atmosphere quiet and relaxed
-reduce or eliminate envir. noises
-get client's attention before speaking
-maintain eye contact
-assume client understand you
-don't rush client
-don't correct client when they make mistakes
-if you don't understand client, ask them to repeat themselves
Ingredients of Therapeutic Communication.
Empathy
Positive Regard
Comfortable Sense of Self
Empathy
The ability to enter into another person's experience to perceive it accurately and to understand how the situation is viewed from the client's perspective.

This is done throught the process of reflective or "active" listening.
Positive Regard
Warmth, caring, interest, and respect for the person, seeing the person unconditionally or nonjudgemental.
Comfortable Sense of Self
Being aware of one's own personality, values, cultural bckground and style of communication.
Non-Therapeutic Response
Interfere with or block therapeutic communication.
Name the Non-Therapeutic Responses
Rescue Feelings
False Reassurance
Giving Advice
Changing the Subject
Being Moralistic
Nonprofessional Involvement
Rescue Feelings
Nurse believes that only he or she can meet the client's needs, alienating himself or herself from the healthcare team
False Reassurance
Giving reassurance that is not based on the real situation. Real reassurance must be based on fact.
Giving Advice
Based on on the nurse's experience and opinions. i.e., I think you should ...
Changing the Subject
usually indicates anxiety on the nurse's part. It is a way of resisting hearing about a client's distress, sadness and difficulties
Being Moralistic
Seeing a situation as good or bad, or right or wrong.
What should you do when dealing with children and adolescent.
-simplify speech
-provide information in a straightforward manner
-play therapy
-personal space and privacy
-limit setting, nurse must be seen as authoritative and being in charge but permitting freedom within reasonable, closely established behavioral limits that elicit participation in their reinforcement.
In which cases are special situations used in communiction with clients
children and adolescents
older adults
cross cultural communications
person in intensive care unit
Learning
Is the acquisition of a skill or knowlege by practice, study or instruction.
Two Learning Theories
Behavioral Learning Theory
Cognitive Learning Theory
Two Approaches to Learning
Pedagogy
Andragog
Pedagogy
The study of traditional classroom instruction.

The art and science of helping children learn.
Androgogy
Based on an individual's need to know something.

The art and science of helping adults learn.
Information Processing
Sensory register, information is stored in short term memory and transferred to long term memory.
Domains of Knowledge
Cognitive -"thinking," learning facts, reaching conclusions, making decisions, or inferring.

Affective -emotions or feelings

Psychomotor - mastering a new taks or skill
Qualities of Teaching-Learning Relationship
Client focus - client education should focus on the client's specific needs.

Holism - consider the whole person (Martha Rogers theory)

Negotiation - nurse and client determine what is already know and what is important to learn

Interactive - dynamic, interactive process that involves participation from nurse and client.
Purpose of Client Education
Wellness Promotion
Disease Prevention
Restoration of Health or Function
Promotion of coping
Wellness Promotion
Education to promote optimum health and function.
Disease Prevention
Teaching clients the knowledge and skills for early detection or prevention of disease ad disabiltiy (i.e. breast self exam.)
Restoration of Health or Function
When illness or dysfunction occurs, client education is important to help limit disability or restore function
Promotion of Coping
New and frightening procedures or adjust and continue to live with chronic illness or disability
Cognitive learning theory
Focuses on what is going on inside a person's head or the thinking process.
Behavioral learning theory
Holds that external environmental forces have a conditioning effect on people to either engage in or avoid certain behaviors.
Cognitive
refers to rational thought, what one generally considers "thinking"
What does Assessment For Learning involve
Baseline Knowledge -finding out about previous client-education experiences may give some indication about where to begin.
-Cultural and language needs
-priorities
-realistic approach - set priorities and try not to teach too much in any one teaching session
*consider energy level
*client's age
*client's emotional state
Assessing Learning Readiness
*Motivation - starts with client's recognition of the need to know.
*Compliance - following or not following the recommended plan
*Sensory and Physical State - -i.e. clients with poor vision for comporomised fine motor skills may be unable to give SQ injections.
*Literacy - ability to read and write
When Planning a teaching session
*Focus on what client needs to know
*Avoid medical terminology
*Cient should be comfortable
*Family members/caregiver may be present
*Uninterrupted time must be available so that meals or necessary treatments do not interrupt the teaching session.
*Teaching should not occur just before an event (ie. discharge, surgery)
Teaching Strategies
*Lectures -formal presentation of informaiton by a teacher to a group of learner (cognitive learning)
*Discussion -exchange of ideas by sharing information, clarifying feelings, or asking questions through active participation
*Demonstration - explaining a skill while demonstrating it.
*Role Playing - acting out feelings or knowledge while another offers guidance and feedback
*Teaching Aids and Resources - pamplets, audiovisuals aids, equipment and models
Evaluation of Learning
Written test
Oral Test
Return Demonstration --skill performance
Check-off List
Simulation - evaluates whether the client can apply learning in different situations.
Implemenation of Client Teaching
*Meeting priority needs first i.e. physiological needs
*Comfortable environment - i.e, privacy is important thus close the curtains, sit near the client, speak quietly and face the client
*Individual Teaching Sessions -i.e, adults vs. children
*Communication
*Repetition
*Teaching methods -cognitive, affective, psychomotor
Lifespan Considerations
Newborn & Infant -learn by interacting with their environment.
Toddler and Preschooler- parents are usually most effective teachers.
Child and Adolescent - understand cause and effect.
Adult and Older Adult - motivated by activities that enhance/maintain self esteem
Exploring
Helps client express their concerns and solve their own problems by investigating the situation and what some alternatives might be
Communication and the Nursing Process
*Assessment
*Intervention
**Helping client get started
-Offering self (making self available to listen to client)
-Open-ended questions (asking neutral quest. that encourage client to ecpress concerns.)
-Opening remarks - (useing general statement based on observation and assessments about the client i.e, "you seem to be feeling better" provide the client w/ opportunity to respond. Avoid asking "Why" question b/c they are intrusive.
-Giving information -sharing relevant info. w/ client about his healthcare and well being.
-Looking at alternatives - helping client see option
-Using silence - allowing for pause in communication that permits nurse and client to think about what has taken place
-Summarizing - highlighting important points in conversation.
*Developing Communication skills - process recording to enhance comm. skills
Active listining
Involves the ability to focus on the client and what the client's message are about, conveying back to the client an accurate picture of what he or she is expressing.
Restatement
Repeating to the client the main content of his/her communciation
Reflection
identifying the main emotion themes contained in a communciation and directing these back to the client
Word Root
Core of the medical term and contains the fundamental meaning of the word. It is the foundation on which other elements are added to develop a complete term.
Derm
Skin

i.e. Dermatos - a term that describes a skin disease
Suffix
Word element place at the end of a word root that changes the meaning of the word
Prefix
Word element attached to the beginning of a word or word root
The process of getting the purpose into code.
Encoding
A medium or carrier of a message.
Channel
A way of being helpful by facilitiating interactions that focus on the client and the client's concern.
Therapeutic communication
Warm, caring interest and concern for the person
Positive Regard
The ability to see into the experience of another and understand how a situation is viewed from the other person's perspective.
Empathy
A message about a message that looks beyond just words.
Metacommunication
The nurse listening and restating content back to the client to verify the nurse's understanding with the client.
Restatement
Asking goal-directed questions to hel.p the lcient focus on key concerns.
Focusing
A pause in communication that allows the nurse and client time to think about what has taken place.
Silence
Elicits more than a yes or no answer.
Open-Ended questions.
Four Major Types of Communication
Written
Verbal
Non Verbal
Metacommunication
Variance
occurs when the client does not proceed along the pathway as planned
Pathways
May look like flowsheets or may use CBE documentation
Clinical Pathways
A way to guide the care of clients who have specific and generally predictable conditions.
Nursing Discharge Summary
Reecord started at initiation of care indicating possible discharge needs and client teaching.
Medication Record
Distinguished between routine and prn medication.
Affective Learning
changes beliefs, attitudes and values
Repitition
May point out deficits in learning that may not be evident in a single session
Communication
A system of sending and receiving messages that forms a connection between the sender and the receiver
Flowsheets
Designed to free the nurse from writing out procedures done repeatedly.