Clinical chapter 5 Flashcards
define communication
the exchange of information
define Verbal communication
way of communicating that uses written or spoken language
define non verbal communication
way of communicating that uses facial expressions, gestures, body language instead of verbal comm
define conflict
discord resulting from differences b/w people; can occur when one person is unable to understand or accept another’s ideas or beliefs
define observation
something that you notice about the pt typically relate to a change in the person’s physical condition
define objective data
info that is obtained directly through measurements or by using one of the five senses
define signs
objective observation compare with symptoms
define subjective data
info that cannot be objectively measured or assessed
define symptoms
subjective observations compare with signs
define reporting
the spoken exchange of info bw hc team members
define recording
communicating info about a pt to other hc team members in writtten form (charting)
define medical record
legal coc with info about pts current condition, the measures taken by staff to dx and treat condition and pts response to treatment and care
define EHR
Electronic health record computer sys that stores and saves person’s med info
define Kardex
card or electric file cntains condensed versions of each pts medical record
define interdisciplinary care plan
specific care plan of care for each pt dev with input from all members of the team
define Nursing Care Plan
specific plan for each pt developed by the nursing team
define nursing process
process that allows members of nuring team to communicate with each other regarding the pts specific needs, what steps will be taken , whether steps were effective, 5 parts 1. assessment, 2. diagnosis, 3. planning, 4. implementation, 5. evaluation
define nursing diagnosis
statement that describes a problem the person is having that can be identified and treated by the nursing staff indep.
define interventions
actions taken by nursing team to help pt
define goals
descriptions of what nursing interventions (actions) are meant to achieve
What is communication
back and forth of info, exchange, with giving and receiving
who are receiver and sender
sender and receiver are the 2 people. Sender has info to share in th form of a message and receiver is who message is intended for
what Is feedback
return message that allows sender know the message was received and understood
what are 2 major forms of communications
verbal and non verbal, verbal incl sign language, is deliberate, expresses thought , gives specific info to another pers. NON verbal is subtle, use of facial express, gestures, body langua tone
4 parts of exchanging information
- sender creates a message, 2. sender delivers message, 3. receiver receives the message, 4. receiver provides feedback
Techniques to enhance communication
- be a good listener, 2. make sure message is clear, 3. learn how to encourage people to talk by using open ended questions, rephrasing, 4 provide and seek feedback, 5. be mindful of body language and tone of voice 6. remember there are time to just be quiet or give a comforting touch
Blocks to effective communication
- not listening, 2. being judgmental, 3. think they already know what you are thinking
Why does conflict occur
conflict is from lack of understanding about beliefs, differing expectations, misunderstanding words or intentions
how to resolve conflict
- speak privately, 2. focus on spec areas of conflict, 3. be spec about what the problem seems to be , 5 use I statements, 6. let the other share what is upsetting, 7. apologize, 8. ask for insights into helping resolv 9. agree to disagree, 10. if have to, seek help
Telephone skills
be pleasant and unhurried, reflects on the facility, confidentiality is king, know wht can be provided over phone
telephone etiquette
- within 3 rings, 2 say good morning, 3. identify self name/title, 4. how may I help, 5. know how to use the phone, 6. mayNOT take drs. Orders, 7. no personal calls
social media
know policies on cell phones, confidentiality, monitoring
what two types of data are used in observation
- objective, and 2. subjective
reporting
is spoken and used to communicate changes, incl observation in pt status, obs. Response to treatment, pt complaint, refusal of tx, pt requests Be accurate, use name and room number, seek feedback
recording
incl medical chart which is a legal document
record - admissions sheet
standard info with demographics and advanced directives
record - med history
detailed med hx form doctor
record - nursing history
completed by nurse at time of admission to facility , related to care, bathing, bladder/bowel habits, dietary pref. ambulation
record - physician order sheet
dr communicates what is to be done for pt
record - MAR, medication administration record
meds orders are listed, dosage, time
record - physiccians progress notes
dr form to record notes on observtion on the persons progress and response to treatment
record - narragive nurses ntes or prog ntes
taken by nursing staff in response to symptoms and actions
record - graphic sheet
info is recorded and documented,
record - miscellaneous docs
lab reports, radiology, dx, therapies,
Why do records help communicate effectively?
reviewing records eliminates steps by everyone reading and responding to what it in the record
What steps are in the nursing process?
assessment, diagnosis, planning, implementation, evaluation
Expand on the nursing process
assess - info is gathered, med hx, nursing hx, family members, abilities, Diagnosis - nursing dx sttes the prob the person is having and what to do about it, Planning - actions and goals , Implementation - inteventions are carried out, Evaluation - checks the interventions effectiveness, Ongoing
comunication in nursing process
observations help dx and decide if interventions are effective
