Exam 2 Flashcards
Communication
The stimulus, the sender or source, the message, the channel, the receiver, and feedback
The stimulus (communication process)
the patient need must be addressed
can be discomfort or desire for information or to address something they might be experiencing
The sender or source (encoder)
communication process
Is a person or group who initiates or being the communication process
The message (communication process)
The actual communication product from the source
-might be a speech, interview, conversation, chart, gesture, memorandum or nursing note
The channel (communication process)
The medium the sender has selected to send the message
- auditory-spoke words and cues
- visual-sight, observation, and perception
- kinesthetic-touch
The receiver (decoder)
communication process
Must translate and interpret the message sent and received
the receiver after they interpret the message they must make a decision about an accurate response
donna just told me she needs to take a shit how tf am I going to help her
Feedback (communication process)
the receiver has understood the intended message
- I tell donna im going to take her to the bathroom
Intrapersonal communication
Self talk is communication within a person
interpersonal communication
occurs between two or more people to exchange messages
small group communication
when nurses interact with two or more people. Communicate to achieve one goal
Organizational communication
occurs when people and groups within an organization communicate to achieve established goals
3 identify the ways patients communicate nonverbally
touch, eye contact, facial expressions, posture, gait, gestures, physical appearance, grooming, sounds, and silence
SBAR
Situation: provides objective data
Background: provides objective data
Assessment: allow for presentation of subjective information
Recommendations: allow for presentation of subjective information
provides a method of hand off communication that is clear, structured, and easy to use
Blocks to communication
Stereotypes, no cliches, no why and how questions, unrequested advice
Phases of helping relationship
Orientation, working, termination phase
Orientation Phase
The tone and guidelines for the relationships are established
you and the patient meet and learn to identify each other by name
get the patient o know you by name in order to built trust
- the established agreement is a verbal exchange related to goals and the means of achieving them
- orient them on hospital protocol
Working Phase
Usually the longest phase
nurse works together with the patient to meet the patients physical and psychosocial needs
provides needed assistance
teacher counselor relationship
Termination Phase
conclusion of the initial agreement
discharge, shift change, nurse vacation, or fired/quit
examine goals and look at the progress towards them
if goals have been reached acknowledge them
Patient Record
is a compilation of a patient’s health information
assessment, nursing diagnoses or patients needs, nursing interventions, and patient outcomes are permanently integrated into the patient record
Patients Rights under HIPPA
See and copy their health record
update their health record
get a list of the disclosures that a healthcare institution has made independent of disclosures made of the purpose of treatment, payment, and health care operations
request a restriction on certain uses or disclosures
choose how to receive health information
Verbal orders
the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency when the physician or nurse practitioner is present but finds it impossible, owing to the emergency situation to write the order
order must be given to a registered professional nurse or registered professional pharmacist, who receives, read back, documents, and executes the order
Steps for verbal orders
A. Record the order in the patient’s medical record
B. Read back the order to verify accuracy of the order
C. Date and not the time the orders were issued during the emergency
D. Record VOs, the name of the physician or nurse practitioner who issued the orders, followed by nurses own name and title
Standalone PHR
patients fill in information from their own record
Tethered/connected PHR
linked to a special health care organization
Source oriented record
a paper format in which each health care group keeps data on its own separate form
