Comprehensive Health Assessment Exam 1

Front 1

define communication

Back 1

N: exchange of info btwn two or more people; exchange of ideas and thoughts; ongoing and dynamic; must be mutual understanding of message
-message must be received and understood at the intent it had. (if asked for advice, provide a way for solving but do not solve).
B: basic component of human relationships. itnent of comm is to get a response and is a process: 1. to influence others 2. to gain information
-communication process is to gain trust and support the client.

Front 2

Levels of Comm. (4)

Back 2

social comm, Intrapersonal Comm, Interpersonal Comm, Therapeutic Comm

Front 3

Social Comm.

Back 3

N: most basic comm
- no deep thought; no specific purpose; may fulfill time gap
-for nurse to greet family members and staff
-be careful that patient doesn't try to turn it in and get information out of you; if so turn it back on them.

Front 4

Intrapersonal Comm

Back 4

N: comm within myself; in touch with words; planning what to say

Front 5

Interpersonal Comm

Back 5

verbal and nonverbal simultaneous comm btwn someone else and self. nonverbal and verbal must compliment each other; this must clarification

Front 6

Therapeutic Comm.

Back 6

N: established in the 1950's by physician to get patient (taught to nurses) to get the patient to talk about themselves to realize their own issues.
-comm that the nurse uses to focus on clients goals and forces them to deal with their feelings
B: comm must have the client expressing the situation and their feelings
- client needs time to deal with feelings; first cope and then deal with other matters like learning new skills and planning for the future.

Front 7

Elements of the process of Comm (6)

Back 7

1. referent
2. source
3. the message
4. channel
5. reciever
6. feedback

Front 8

1. referent

Back 8

reason for engaging in the exchange

Front 9

2. Source

Back 9

(encoder) person that will send message; starts conby comm, conversation; influenced by comm skills, attitude toward topic, knowledge of topic, language skills, social cultural system and motor skills for writing; concrete
B: Encoding= involves the selection of specific signs or symbols (codes) to transmit the message (considerate of the lay-person)

Front 10

3. The message

Back 10

what is said or written; concrete expression expression of ideas; must present in recognizable format.
B: the nonverbal channel of touch is often highly effective

Front 11

4. Channel

Back 11

method or route selected to send the message; when dealing with channel must incorporate as many senses as possible ; must be appropriate

Front 12

5. Receiver

Back 12

(decoder) person to whom the message is being sent; has to perceive the message the way sender intended; must analyze and provide feed back; will use same comm skills to influence way of understanding

Front 13

6. Feedback

Back 13

message back to send with confirmation; determines success or failure of process

Front 14

Modes of comm. (4)

Back 14

Verbal comm, nonverbal comm, electronic comm, interview

Front 15

Verbal Comm

Back 15

spoken or written word in a common language; receiver has to be conscious ; based on culture , age , socioeconomic level, education; nurses must have command of this like charting and memos
B: for verbal must have:
1. pace and intonation
2. simplicity
3. clarity and brevity
4. timing and relevance
5. Credibility
6. humor

Front 16

Nonverbal Comm

Back 16

body language; may speak louder than verbal; it can either reinforce or contradict; this will believed before verbal
-Example: facial expression, eyes, no matter how negative situation must always stay positive, brows, eye movement, eye contact (depends on culture). lips, body movement, posture, space given (comfort), and touch
B: Examples personal appearance, gestures, posture and gait, facial expression

Front 17

Electronic Comm

Back 17

forces nurses to chart in a timely fashion; HIPPA with main health doctor; transfer of info
B: emails
Advantage: its a fast efficient way to comm and it is legible.
Disadvantage: risk of client's confidentiality and socioeconomics because not everybody has a computer or access to an electronic device

Front 18

Interview

Back 18

(use when therapeutic comm) represent a helping relationship; the goal to help patient to identify behavior; competent enough to help solve, only can tell patient but cannot do
-effectiveness= patient develop trust, respect, and acceptance with nurse or person comm.

Front 19

Phases of interview (4)

Back 19

1. preinteraction
2. Introductory phase
3. working phase
4. termination phase

Front 20

1. preinteraction phase

Back 20

go in to the patient know what to do
B: similar to the planning phase stage before an interview ; nurse gathers patients info before seeing them.

Front 21

2. Introductory phase

Back 21

sets mood; if patient will have trust then clarify role.
B: aka orientation phase and prehelping phase
-stes tone of the relationship; goal is to determine develop trust and security btwn the nurse and patient. must get to know each other to develop trust.
-opening relationship, clarifying the problem, structuring and formulating the contract (obligations to be met by both the nurse and patient)

Front 22

3. Working Phase

Back 22

listening and gathering the information; finding mutual understanding; have clarifications
B: exploring and understanding thoughts and feelings ; facilitating and taking action

Front 23

4. Termination Phase

Back 23

ending properly
B: nurse and client accept feelings of lost in which the client accepts the end of the relationship without feeling of anxiety and dependence (summarize).

Front 24

Important guidelines in nurse and patient relationship

Back 24

-be aware of trust: confidentiality (legal aspect)
- comm is not social
-patient must have independence
-send diagnosis to doctor
-let patient have choice
- respect and move on

Front 25

barriers to effective comm (11)

Back 25

1. vocab (using wrong, abstract, slang, or medical terms that lay person cant understand)
2. give a flip or glypse statement ; false reensurance ( not what you say it's how you say it)
3.message isnt clear or poor choice of words
4. given unasked opinion or personal experiences
5. environment= where are you talking about and are you in the middle of it (what, when , how, ask)
6. belittle patient (tend to do this with children)
7. defensive with what we say or argumentativeness (basically nurse saying you have no right to complain)
8. stereotyping
9.agreeing or disagreeing
10. Challenging the patient (basically dont have a smart mouth to a patient even if they are exaggeration)
11. rejecting or changing topics

Front 26

techniques to facilitate comm

Back 26

1. genuine, warm, concern, interest, clear, concise, and attentive, listen encourage, aware of cultural differencesand don't interrupt
2. see clarification
a. closed statement
b. open ended statement
3. Reflection

Front 27

a. closed ended statement

Back 27

a specific and short answer that doesn't let patient expand (how old are you?)

Front 28

b. open ended statement

Back 28

allows patient to talk about statement (Tell me about your pain).
B: Rather than ask " do you understand what to eat?" you should ask "what do you think will be good for you to eat when you go home?"

Front 29

Reflection

Back 29

making the client understand what is best for themselves through asking them the same question

Front 30

Age span affect

Back 30

you must know the development level in which the patient is in
-the child and adult are separate

Front 31

Communication with infant

Back 31

-only communicate through crying and loudness of the cry
-like to feel touch and smooth voice

Front 32

Comm with Toddlers and Preschoolers

Back 32

- give time to express themselves
- use short sentences
-don't use baby talk
-child needs to interact with eye contact and never physically be looking down on them (must be on same eye level)

Front 33

Comm with school age

Back 33

-give time for child to respond
- tell parent to have patience in an appropriate manner
-talk on eye level to decrease intimidation

Front 34

Comm with Adolescents

Back 34

- able to listen to them
-not be judgmental

Front 35

Comm with Older Adults

Back 35

-keep distractions around to a minimum
-look for physical to mental impairments to a minimum, speak short and simple but don't elder speak
- always face someone
-

Front 36

Impairments to Communication (5)

Back 36

language deficits, sensory deficits, cognitive impairments, structural deficits, paralysis

Front 37

techniques used in communication with the clients in special circumstances :
CRYING

Back 37

it's okay to cry (may be contagious) ; give privacy, offer tissue, be quiet, ask if they want to be left alone or comforted
- if you cry= leave the room

Front 38

techniques used in communication with the clients in special circumstances :
VISUALLY IMPAIRED

Back 38

provide touch
- before identify yourself and then ask for permission
- when touching provide orientation
-last tell them when you are leaving
-Remember to talk in normal talk, not elder speak

Front 39

techniques used in communication with the clients in special circumstances :
HEARING IMPAIRED

Back 39

-make lips visible and nothing in the mouth
-use simple sentences
-ask if patient has hearing on and assure that it's on.
- make sure they see your face
-check if the patient is using their hands to comm

Front 40

techniques used in communication with the clients in special circumstances :
UNCONSCIOUS PATIENT

Back 40

address patient as if they were wide awake
-speak before touch
-look for any indications of comprehension
-ask question and look for little reactions

Front 41

techniques used in communication with the clients in special circumstances :
FOREIGN LANGUAGE

Back 41

-translator (maybe family or staff can interpret)
-emphasize on nonverbal
-set up something in their language
-don't raise voice

Front 42

HIPAA

Back 42

Health Insurance Portability and Accounting Act=
-started to be kennedy and passed by clinton
-allows health insurance to have privacy allow continually to care
-ask if it's okay or not okay to send information to other health care facilities

Front 43

Nursing Process

Back 43

a systematic dynamic process of planning and providing individualized nursing care
-allows nurse to deal with the client
- purpose= to identify the client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet the needs

Front 44

Elements to critical thinking (5)

Back 44

1. collect information: identify assumptions, organize data, determines what is consistent, determine reliability, and it relevance
2. analysis
3. Generation of alternatives
4. selection of alternations
5. evaluations

Front 45

Critical thinking toward to the nursing process

Back 45

cognitive skill; purposeful/ creative; more than problem solving; enhances application to the nursing process
B:
-nurses use knowledge from other subjects and fields
-nurses deal with change in stressful environments
-nurses make important decisions

Front 46

nursing process steps

Back 46

1. assessment
2. diagnosis (sometimes put together with assessment)
3. Plan
4. Implementation
5. evaluation

Front 47

Assessment

Back 47

collection of Data
-systematic, organized, project client you know
-continual= chart/ don't throw something away
-ongoing= review chart/ data may change
-performed with all steps and directly influenced

Front 48

type of data

Back 48

subjective= coming from the patient (symptoms: itch, nauseous, painful, patient experienced )
objective= measurable data (signs: cyanosis, pulse, chest sounds); can be INSPECTED, PALPATED, AUSCULTATION, AND PERCUSSION

Front 49

Source of Data

Back 49

Primary and secondary

Front 50

Primary data

Back 50

client; always first if possible

Front 51

secondary data

Back 51

other sources of data like family or friend, records or charts

Front 52

Nursing Diagnosis

Back 52

a clinical judgement made about the client
-focused around actual problems and potential
-provides basis for outcomes and goals/ nursing interventions/ orders

Front 53

Parts of Nurse diagnosis

Back 53

1. problem
2. etiology
3. signs and symptoms

Front 54

Problem

Back 54

what is happening to the patient here and now
(stated from NANDA)
-source of goal or outcome

Front 55

etiology

Back 55

what is cause of problem
-will be the source for nursing interventions

Front 56

sign and symptoms

Back 56

what the nurse is able to see/ hear

Front 57

medical diagnosis

Back 57

A medical diagnosis focuses on the illness. A nursing diagnosis focuses on the person and their physiological and/or psychological response to the illness. Doctors formulate medical diagnoses to treat medical problems; as nurses, we then care for the person behind that illness

Front 58

Planning

Back 58

-set priorities (rack order (most threatening dealt first)
-state outcomes and goals
-identifying nursing interventions
-begin discharge planing

Front 59

long term goal

Back 59

-more global/ not specific
- needs more time to achieve
-source for short term goal
- example: patient will progress to a regular diet w/3months

Front 60

short term goal

Back 60

-specific
-flows from short term goal
-easy to achieve
-example: patient will drink 30ml of water every two hours on the half of hour

Front 61

Goal statement

Back 61

- must have subject= patient
- must have verb= action being performed
-EX: patient will be able to drink
- must have a condition= explains circumstances (what, where, when, and how)
-Criteria= evaluation via a standard not always used or needed
*always stated in patient terms not nurse.*

Front 62

Interventions/ Orders

Back 62

activities put into action to reach goal
-comes from the R/T (reaction to) part of nursing diagnosis
-independent: do what's important, no doctor needed like with meds
- dependent: doctor needed like for prescription
- collaborative: done with other team members like passage range of motions

Front 63

Implementation

Back 63

providing care
-putting into action to plans that are created
-document care given
-response to treatment
-delegation of responsibilities

Front 64

evaluation

Back 64

planned ongoing activity
-does not imply failure if goal is not reached
-determines goal achievement and the effectiveness of the interventions for reaching the goal

Front 65

Standards for RN

Back 65

ANA
Nurse practice act
American Association of College of Nursing
-Commission of College of Nursing education

Front 66

ANA

Back 66

standard of care
-5steps of the nursing rpocess
standards of professional performance
-uses variety of resources
Code of ethics (standards of practices)
-ideals and values of nursing
- standards for practice

Front 67

Nurse Practice Act

Back 67

(unique to each state)
-a legal act
-developed by state
-regulate practice of nursing
-common purpose= protects public and staffs health

Front 68

CCNE

Back 68

(Commission of College of Nursing education)
-accrediting agency
-provide standards of education (9)
- program is expected to meet standards
-solid based in liberal education
- knowledge and skill in leadership
-evidenced based practice
-care based on nursing practice

Front 69

Health (general)

Back 69

state of being physical, emotional, and mental well being; not disease

Front 70

disease

Back 70

a disorder of bodily function; dysfunction/ destruction of the body; produce recognizable signs and symptoms

Front 71

health (webster)

Back 71

state being sound and whole in bod, mind and soul; state of being free of physical disease and pain

Front 72

health (roy)

Back 72

a process and a state of being and becoming whole and integrated in a way that reflects the person and environment in a mutual fashion

Front 73

health (Nightgale)

Back 73

a state of well being, uses every power to a person's possession to fullest extent

Front 74

Wellness

Back 74

a part of health
-an active process of being aware and making a choice in which we are able to have a successful existence
-social, occupational, spiritual, emotional, physical, cultural, and environment
-physically in harmony (ecologic model; not hollistic thus wrong)
-takes care of self
-not mere absence of disease, must be proactive

Front 75

Illness

Back 75

state of discomfort which arises when health becomes impaired
-cause is stress, accident, injury
subjective= if patient felt disease individually
*disease/ illness/ sickness are different*

Front 76

Medical Model

Back 76

dominant in the US
-Insurance