Clinical chapter 5

Question 1

define communication

Answer 1

the exchange of information

Question 2

define Verbal communication

Answer 2

way of communicating that uses written or spoken language

Question 3

define non verbal communication

Answer 3

way of communicating that uses facial expressions, gestures, body language instead of verbal comm

Question 4

define conflict

Answer 4

discord resulting from differences b/w people; can occur when one person is unable to understand or accept another’s ideas or beliefs

Question 5

define observation

Answer 5

something that you notice about the pt typically relate to a change in the person’s physical condition

Question 6

define objective data

Answer 6

info that is obtained directly through measurements or by using one of the five senses

Question 7

define signs

Answer 7

objective observation compare with symptoms

Question 8

define subjective data

Answer 8

info that cannot be objectively measured or assessed

Question 9

define symptoms

Answer 9

subjective observations compare with signs

Question 10

define reporting

Answer 10

the spoken exchange of info bw hc team members

Question 11

define recording

Answer 11

communicating info about a pt to other hc team members in writtten form (charting)

Question 12

define medical record

Answer 12

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

Question 13

define EHR

Answer 13

Electronic health record computer sys that stores and saves person’s med info

Question 14

define Kardex

Answer 14

card or electric file cntains condensed versions of each pts medical record

Question 15

define interdisciplinary care plan

Answer 15

specific care plan of care for each pt dev with input from all members of the team

Question 16

define Nursing Care Plan

Answer 16

specific plan for each pt developed by the nursing team

Question 17

define nursing process

Answer 17

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

Question 18

define nursing diagnosis

Answer 18

statement that describes a problem the person is having that can be identified and treated by the nursing staff indep.

Question 19

define interventions

Answer 19

actions taken by nursing team to help pt

Question 20

define goals

Answer 20

descriptions of what nursing interventions (actions) are meant to achieve

Question 21

What is communication

Answer 21

back and forth of info, exchange, with giving and receiving

Question 22

who are receiver and sender

Answer 22

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

Question 23

what Is feedback

Answer 23

return message that allows sender know the message was received and understood

Question 24

what are 2 major forms of communications

Answer 24

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

Question 25

4 parts of exchanging information

Answer 25

1. sender creates a message, 2. sender delivers message, 3. receiver receives the message, 4. receiver provides feedback

Question 26

Techniques to enhance communication

Answer 26

1. 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

Question 27

Blocks to effective communication

Answer 27

1. not listening, 2. being judgmental, 3. think they already know what you are thinking

Question 28

Why does conflict occur

Answer 28

conflict is from lack of understanding about beliefs, differing expectations, misunderstanding words or intentions

Question 29

how to resolve conflict

Answer 29

1. 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

Question 30

Telephone skills

Answer 30

be pleasant and unhurried, reflects on the facility, confidentiality is king, know wht can be provided over phone

Question 31

telephone etiquette

Answer 31

1. 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

Question 32

social media

Answer 32

know policies on cell phones, confidentiality, monitoring

Question 33

what two types of data are used in observation

Answer 33

1. objective, and 2. subjective

Question 34

reporting

Answer 34

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

Question 35

recording

Answer 35

incl medical chart which is a legal document

Question 36

record - admissions sheet

Answer 36

standard info with demographics and advanced directives

Question 37

record - med history

Answer 37

detailed med hx form doctor

Question 38

record - nursing history

Answer 38

completed by nurse at time of admission to facility , related to care, bathing, bladder/bowel habits, dietary pref. ambulation

Question 39

record - physician order sheet

Answer 39

dr communicates what is to be done for pt

Question 40

record - MAR, medication administration record

Answer 40

meds orders are listed, dosage, time

Question 41

record - physiccians progress notes

Answer 41

dr form to record notes on observtion on the persons progress and response to treatment

Question 42

record - narragive nurses ntes or prog ntes

Answer 42

taken by nursing staff in response to symptoms and actions

Question 43

record - graphic sheet

Answer 43

info is recorded and documented,

Question 44

record - miscellaneous docs

Answer 44

lab reports, radiology, dx, therapies,

Question 45

Why do records help communicate effectively?

Answer 45

reviewing records eliminates steps by everyone reading and responding to what it in the record

Question 46

What steps are in the nursing process?

Answer 46

assessment, diagnosis, planning, implementation, evaluation

Question 47

Expand on the nursing process

Answer 47

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

Question 48

comunication in nursing process

Answer 48

observations help dx and decide if interventions are effective