Comfort/Pain, Communication, Documentation

Question 1

Pain truths?

Answer 1

Pain is universal, the most common reason for seeking medical care, subjective and highly individualized.

Question 2

Origins of pain?

Answer 2

Cutaneous, superficial, visceral, deep somatic, radiating, referred, phantom, psychogenic

Question 3

Acute pain?

Duration, purpose, pattern?

Answer 3

Short lived, under six months, transient. Purpose is warning that something is wrong. Pattern is self limited and readily alleviated

Question 4

Acute pain?

Localization, clinical signs, prognosis?

Answer 4

Localization is generally well confined and identified. Signs are high BP, HR, R ( sympathetic activity. Initial physiologic response. Prognosis is good once the underlying problem is resolved.

Question 5

Chronic pain?

Duration, purpose, pattern?

Answer 5

Longer than six months. Somethings happening in the body. Pattern can be continuous or intermittent, intensity varies.

Question 6

Chronic pain?

Localization, clinical signs, prognosis?

Answer 6

Localization is well define and indistinct. Signs, the body adapts, vital resume to the norm, and pain does not decrease. Prognosis is that complete relief is not possible.

Question 7

When to assess for pain?

Answer 7

During each initial shift assessment. Before and after every procedure or treatment that’s potentially painful. Before and after pain intervention per facility policy. With every vital check. With every report of pain.

Question 8

What to asses for pain?

PQRST

Answer 8

Provoking-precipitating factors
Quality, what it feels like
Region/radiation-location
Severity-intensity
Time-onset, duration, frequency

Question 9

What do nurses with expert communication skills do?

Answer 9

Express caring, take initiative, believe nurse-client relationship is equal to partnership, appreciate uniqueness, include patient/family/cultural consideration, use critical thinking

Question 10

What are the levels of communication?

Answer 10

Intrapersonal: self talk
Interpersonal: between two people
Small group: small number of people
Public: with an audience
Electronic: technology

Question 11

Explain the circular transition model of communication

Answer 11

Referent, sender, receiver, message channels, feedback, interpersonal variables, environment

Question 12

Phases of the helping relationship?

Answer 12

Preinteraction, orientation, working, termination

Question 13

Possible nursing diagnoses for communication?

Answer 13

Anxiety, social isolation, ineffective coping, compromised family coping, powerlessness, impaired social interaction, impaired verbal communication

Question 14

Active listening SOLER?

Answer 14

Sit facing the patient
Observe an open posture
Lean toward the patient
Establish and maintain intermittent eye contact
Relax

Question 15

What is documentation and what does it do?

Answer 15

Record of proof for authorized persons, either paper or electronic. Reflects the quality of care. Provides evidence of each health care team member’s accountability in giving care.

Question 16

What are the legal guidelines for recording?

Answer 16

Correct all errors promptly. Record all facts, no personal opinions. Do not leave any blank spaces in notes. Write in black ink. Chart only for yourself. Avoid generalizations. Keep pw secure.

Question 17

What makes up quality documentation?

Answer 17

Factual, accurate, complete, current, organized

Question 18

Paper documentation

Answer 18

Episode-oriented. Key information may be lost from one episode of care to the next.

Question 19

Electronic health record (EHR)

Answer 19

Digital version of a patient’s medical record. Integrates all of a patient’s information in one record. Improves the continuity of care.

Question 20

Problem-oriented medical record?

Answer 20

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Question 21

SOAP
PIE
DAR

Answer 21

Subjectivem objective, assessment, plan
Problem, intervention, evaluation
Data, action, response

Question 22

Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.

Answer 22

Admission nursing history form

Question 23

Help team members quickly see patient trends over time and decrease time spent on writing narrative notes

Answer 23

Flow sheets and graphic records

Question 24

Includes meds, diet, community resources, follow-up care, emergency contacts. Recorded as discharge teaching.

Answer 24

Discharge summary forms

Question 25

Occurs with the transfer of patient care. Provides continuity and individualized care. Quick and efficient.

Answer 25

Hand-off report.

Question 26

I-SBAR or SBAR

Answer 26

Introduction
Situation
Background
Assessment
Recommendation