Exam 1: Nursing Process/Communication Flashcards
What are the differences between a nursing diagnosis and a medical diagnosis?
Treat Disease vs Illness
- Medical interventions (medication,
surgery, etc.) - Nursing interventions (call light
education, pain assessments, side
rails up, etc. ) - Medical goal is to cure disease.
- Nursing goals are in collaboration
with patient needs and their
response to illness
How does a nurse utilize assessment data to formulate a nursing diagnosis?
Organize Data – Cluster information
Must recognize cues
Where do you find a list of available nursing problems to apply to your client?
NANDA-I
What are the characteristics of the related to (etiology) factor in a nursing diagnosis?
- Factors that led to the nursing diagnosis
- Can be treated by a nurse independently or collaboratively
- Is not the medical diagnosis
Define the 3 parts of a problem-based nursing diagnosis.
Problem Focused - 3-part
Diagnosis
r/t
AEB
Ex: Acute pain related to traumatic injury as evidenced by 7 out of 10 on pain scale.
What are the 3 types of nursing diagnoses?
Problem Focused Diagnosis
Risk Nursing Diagnosis
Health Promotion Diagnosis
How do symptoms/evidence/defining characteristics lead to the formulation of a nursing diagnosis?
Signs and symptoms gathered during assessment -> This assessment data leads to the nursing diagnosis -> Use the phrase “as evidenced by”
When would you use a 2 part nursing diagnosis?
Risk Diagnosis - 2-part
* Diagnosis, related to factor
* Cannot have AEB because the client has not experienced the alteration in health
Health Promotion - 2-part
* Diagnosis, as evidenced by
AEB is pt statement
What are the characteristics of a Care Plan Goal?
Specific
Measurable
Attainable
Realistic
Timed
What are the five components of a nursing care plan?
Assessment
Diagnose
Plan
Intervention
Evaluation
How do nursing interventions support your plan of care?
nursing actions that will help to reach the client’s goals that can be independent or collaborative
nurses’ scope of practice
interventions should focus on caring for the client/family to allow them to function at their highest level
What do you do if the care plan goal is not met?
Change goals/interventions
communicate, evaluate, reassess
Why is building a therapeutic relationship important to nursing practice?
Builds trust with patient so that both can be productive towards goals
to effectively deliver care, we need to communicate
How does a nurse build a therapeutic relationship?
mutuality - express partnership
When do nurses begin to establish the therapeutic relationship?
Before the first interaction w/ planning and reading chart
“hello”
What is the first step in defining roles within the nurse-patient relationship?
mutuality - equal participants -> express this dynamic so that it isn’t a negative power balance
First interaction w/ the patient
What are the characteristics of the therapeutic relationship?
Specific Time Frame
Goal-directed approach
Confidentiality
Non-judgmental acceptance
Patient’s needs are the priority
Describe the 4 goal-directed phases of the nurse patient-relationship?
Pre-interaction Phase
Orientation Phase
Working Phase
Termination Phase
What are elements of professional communication?
- Professional Appearance
- Courtesy
- Use of Names
- Trustworthiness
- Autonomy and Responsibility
- Assertiveness
What are some therapeutic communication skills that form and maintain the therapeutic relationship?
- Non-verbal communication
- Active Listening
- Using Touch
- Narrative interaction/Self-disclosure
- Empathy
- Relevant Questions
What is the purpose of SBAR?
Clear communication to minimize medical errors and be efficient
What are the components of an SBAR?
Situation
Background
Assessment
Recommendation
