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Therappeutic communication

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-a learned skill (unnatural) -focuses on client

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Types of communication

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-written -verbal -non-verbal -metacommunication

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Written communication

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documentation, instructions for procedures, medication information, s bar notes (ways to communicate with healthcare providers), different societies

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Verbal communication

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Talking between people, giving report

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Non-verbal communication

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One of the most important types of communication.

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Congruence

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Make sure that verbal and nonverbal communications match. Can be gestures, posture, facial expressions, distance, appearance

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Metacommunication

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Communication about communication. Critical thinking about communication, intrapersonal communication about the communication process

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Interpersonal communication

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communication between 2 people

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Intrapersonal communication

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communication with yourself (self thoughts)

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Transpersonal communication

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communication with spiritual self/could be prayer

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Verbal communication

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-vocabulary (need to be cautious--avoid medical jargon) -pacing -intonation (tone of voice says a lot) -clarity and brevity (don't sugar coat, get to the point, avoid small details) -timing and relevance (make sure timing is appropriate especially when explaining medians, procedures, etc.)

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Non-verbal communication

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-personal appearance -posture and gait -facial expression -eye contact -gestures -territoriality and personal space

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Zones of personal space

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-intimate zone: 0-18 in -personal zone: 18 in-4 ft -social zone: 4 to 12 ft -public zone 12 ft and beyond

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The communication process: elements

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-sender -encoding -communication channel -receiver -decode -feedback

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Factors effecting communication

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-altered sensory perception -language -personal history (culture, parenting, experience, etc.)

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Noise

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anything that distracts the communication process

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Dysphagia

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gag

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dysphasia

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speech

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wernicke

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receptive trouble. Can't understand what someone is saying, having trouble receiving communication

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Broca

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expressing trouble. Know what you want to say, but can't say it. Comes out broken.

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Nurse-client relationship phases

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-orientation (establish trust/rapport) -working (develop and implement solutions to concerns and evaluate interventions) -termination (closure of relationship) *go through every phase every time you walk into patient's room *should be talking about termination during orientation phase (giving patient time frame on how long interaction will last) *teaching termination during beginning of interation

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Empathy

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not showing emotions but feeling for the person in that situation

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Nursing diagnoses

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signs and symptoms of disorder. Ex: pain, impaired verbal communication, anxiety, powerlessness

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Therapeutic communication techniques

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-offering self -open ended questions (give patient best opportunity to explain more than just one word response) -active listening -restatement -reflection -giving information (allowed to give information but cannot give advice -silence -appropriate humor *IF DNR CCO: can only do modalities to help with pain/comfort--cannot give CPR, electric shock, or intubation

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Non-therapeutic communication techniques

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-rescue feelings/codependency (nurses are there to help, not there to rescue patients) -false reassurance (can only state facts) -giving advice -sharing personal opinions -changing subject -being moralistic -asking for explanations -non-professional involvement

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Defense mechanisms

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-compensation -conversion (repression of anxiety, unconsciously transforming anxiety into non-organic symptom--ex: loss of appetite) -denial -displacement -suppression -repression (not trying to not think about it--subconscious just does not believe it happened) -identification -projection -regression -sublimation (having urges to walk around naked, but instead writes songs about it)

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Conceptual frame works of nursing

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what is in and outside of nursing

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nursing theory

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link the conceptual frameworks

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Florence nightingale

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-founder of modern nursing -began nursing research during the Crimean War (noticed relationship between environment and health -Theory of sick nursing vs. well nursing (primary, secondary, tertiary)

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Primary

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disease prevention: immunization, hand washing, wearing seatbelt, fluoride in water, etc.

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Secondary

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early detection and treatment: going for annual checkups

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Tertiary

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trying to get patient back to "well" at the highest level possible:rehab, recovery, post surgery phase

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Dorthea Dix

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Established the Nurse Corps of the United States Army

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Clara Barton

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Organized American Red Cross

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Skill acquisition in nursing education

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-novice -advance beginner -competent

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Noive

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-governed by established rules -behavior is limited and inflexible due to lack of knowledge -textbook: black and white

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Advanced beginnner

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-Exhibit marginally acceptable performance -principles to guide actions begin to be formulated -principles are based on experience -start to form own theories and thoughts, task checklist based

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Competent

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-begins following 2-3 years of nursing practice -conscious deliberate planning to achieve organization and efficiency

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Proficient

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Good at what you do

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Expert

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-uses intuition and psychological and social aspects as well

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4 constructs to a nursing theory

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1. nursing 2. person 3. health 4. environment

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Nightingale

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-concentrated on environment -addressed sick nursing vs. well nursing -health/hygiene and how the environment effects health

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Peplau

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-concentrated on interpersonal interaction -interaction between the nurse and patient, patient and doctor, doctor and nurse -patients functions cooperatively with nurses and doctors (patient has most important voice

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Henderson

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-concentrated on client/patient independence -nature of nursing -getting patient as independent as possible -believed you couldn't be physically well if you weren't psychologically well

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Rogers

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-concentrated on unitary man/energy fields -believed in energy fields -could see an aura in patients and the energy they were giving off -nursing is not just science, it is also an art -thought that person is more than just a sum of their parts

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Orem

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-concentrated on self-care -getting patient to take care of themselves -said there were 3 interacting systems

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King

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-humans are constantly interacting with their environments: 1. personal 2. interpersonal 3. social

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Neuman

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-systems -adopted King's systems -said that most important is stress and how you react (coping) -focused on distress and how to help patient cope

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Roy

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-adaptation theory -built on King and Neuman's systems -took Neuman's ideas on stress and coping and added adaptation to it (changing their belief system/make a lifestyle change)

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Watson

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-caring -got back to the route of it all -not just treating disease/illness, but need to care for them -caring is essential to nursing

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Parse

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-man-living-health unity -pushed quality of life vs. quantity of life

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General systems theory

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-sum is greater than all of its parts -holistic approach

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Maslow's hierarchy of needs

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-physiological needs (Basic needs:food, water, warmth, rest) -safety needs (basic needs: security and safety) -belongingness and love needs (psychological: intimate relationships, friends) -esteem needs (psychological:prestige and feeling of accomplishment) -self-actualization (self-fulfillment needs: achieving one's full potential, including creative activities) **physiological needs are most important

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Lewin's change theory

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-unfreezing -movement -refreezing

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ABCs

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-Airway -Breathing -Compressions *Except for CPR: CAB

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Health history

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-family history -previous surgeries -medications -etc.

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Gene history

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-family medical history -parents -grandparents -siblings -children

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physical assessment

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-getting hands on patient 1. Inspection 2. Percussion 3. Palpation 4. Auscultation

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Inspection

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looking for abnormalities

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Percussion

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listening for residence (bone vs. fatty tissue)

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Palpation

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induration (hardness and raised)

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Auscultation

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listening (usually use stethoscope)

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Abdominal assessment

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1. Inspection 2. Auscultation 3. Percussion 4. Palpation *Order is changed because when you press down on abdomen you can change the rate of bowel sounds

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Purpose of health assessment

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-establish database of client's abilities (baseline data) -compare assessment findings with medical diagnosis to decide if more data is needed -organize into systems (cardiac, etc.): use Gordon's function health patterns (FHP) -Head to toe assessment

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Functional assessment

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Gordon's functional health patterns (FHP)

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Head to toe

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organized manner, head to toe

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Body systems assessment

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focus on specific body systems

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Primary data

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-information from the client *if patient is in coma/non responsive--you cannot get primary data. Patient is only person who can give you primary data!

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Secondary data

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-information from other than the client -usually collect secondary data first

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Culture (health assessment)

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the nurse's unconscious biases may influence data

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Assess health perception

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client's perspective of their health status

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assessment of activity and exercise

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-posture -gait and balance -decreased mobility (not always muscular and skeletal: often times COPD)

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assessment of nutrition and metabolism

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dietary habits and metabolism

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Obtaining subjective data

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-assessment of elimination -assessment of rest and sleep -assessment of cognition and perception -assessment of self-perception and self-concept -assessment of roles and relationships -assessment of coping and stress -assessment of sexuality and reproduction -assessment of values and beliefs

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clinical manifestations

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subjective + objective data

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Normal urine output (times per day)

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5-7 times per day

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Normal urine output each elimination

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200-300ml (1500ml/day)

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Minimum urine output per day

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720 ml excreted per day 30ml/hr 240ml/8 hour shift

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Renal failure due to decreased output

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when kidneys produce less than 400ml/day

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oliguria

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insufficient urine production

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polyuria

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too much urine production

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frequency

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going to the bathroom often

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Alert and oriented x4

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1. name 2. place 3. time 4. why *can use colloquialisms

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obtaining objective data: physical examination

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-use of senses to obtain information about the client's ability to function -positioning (draping helps ensure privacy) -inspection, palpation, percussion, auscultation -general survey (overall appearance of the client)

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Insepction

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-physical observations of the client -looking for symmetry -with elders and young children thermoregulation is important--especially while washing!

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Palpation

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-using hands, touch to gather data -finger tips are good to indicate texture changes -palms of hand are good for tactile vibration -dorsal of hand good for temperature

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Percussion

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-tapping of an area of the client's body to produce sound

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Auscultation

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use of stethoscope to hear sounds in the client's body

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Newborn and infant considerations

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-keep covered -involve parents -keep covered-loose heat fast especially through the head

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Toddler and preschooler considerations

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-involve parents -explain in simple terms

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School age child and adolescent considerations

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-proper draping -honest answers to questions -be cautious with therapeutic touch since touching at this age is iffy

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Adult and older adult considerations

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-prepare client for all procedures -provide privacy -older clients can be chilled easily -make accommodations for limitations in flexibility

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Nursing process

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-Systematic problem solving approach designed to address the needs of individual patients, families, and communities -5 steps: Assessment, diagnosis, planning, implementation, evaluation

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Assessment

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-Gathering data: signs and symptoms, and then organizing the data -primary and secondary data

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Diagnosis

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-Identifying problem and prioritizing problems -Client centered -Nurses cannot diagnose diseases, but can say "at risk for..."

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NANDA

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North American Nursing Diagnosis Association - addresses the need for common language/goals for all nurses -are endorsed by ANA

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ANA

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American Nurses Association -lobby on nurses behalf -have code of ethics

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3 types of nursing diagnosis

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1. Actual 2. Risk for 3. Wellness

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Actual nursing diagnosis

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1. diagnosis 2. related to (R/T) 3. as evidence by (AEB)

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Risk for nursing diagnosis

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1. diagnosis 2. R/T *Avoid medical diagnosis, if you must, add "second to" before diagnosis

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NOC

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-code for nursing interventions and outcomes to medically bill patient

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Outcome criteria/goals

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makes sure they are: -measurable -realistic -client centered

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Planning

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Identify nursing strategies to: -direct care, promote continuity of care, focus charting -provide for delegation of specific patient care activities -Nursing Intervention Classification (NIC)

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Implementation

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-Actual initiation of identified interventions and care activities -Types: direct, indirect, cognitive, interpersonal, technical -Reassess if needed, set priorities, perform nursing interventions, record and document nursing interventions

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Direct care measures

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-ADLs -Physical care techniques -Counseling -Teaching -Controlling for adverse reactions -Preventive measures

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Indirect Care measures

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-Communicating nursing interventions -delegating, supervising, and evaluating the work of other staff members

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Evaluation

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-review patient goals and determine if expected outcome criteria were met/achieved (collect data to identify patient's response to interventions, measure goals/outcome achievement) -document degrees of goal attainment -terminate, continue, or revise/modify plan of care

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Outcome evaluation

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met, not met, partially met

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Process evaluation

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-have to evaluate process if goal was not met

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Care plan revisions

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-discontinue -modify: reassess, nursing diagnosis, client goals and outcomes, and nursing intervention

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