Final Objectives Flashcards
Describe the various modes of communication & justify when a specific mode of communication may be necessary.
Nonverbal communication, communication with children & adolescents, communication with older adults, cultural considerations
Differentiate between attentive listening & physical attending as they apply to therapeutic communication & the nurse-client relationship.
Active listening means you are actually listening to their problems and physical attending means you are actually attending to their needs
Demonstrate therapeutic communication techniques, indicating when each might be of particular use when providing client care.
Open-ended questions: broad questions that allow client a wide range of responses, specifies only topic to be discussed and invite answers that are longer than 1 or 2 words
Close-ended questions: allows limited choices of possible responses like yes or no. Used to gather specific info and there are appropriate uses, but could become a barrier.
Validating: serves to validate/confirm what the nurse believes has been heard or observed.
Clarifying: an attempt to understand the basic nature of a clients statement
Reflective: what takes place when the nurse repeats the clients verbal/nonverbal message for the clients benefit
Sequencing: used to place events in a chronological order or to investigate a possible cause-and-effect relationship between events
Directing: used to obtain more info about a topic mentioned previously or to introduce a new aspect of the current topic
Describe barriers to successful communication & suggest strategies to reduce the risk of each barrier.
Failure to perceive the client as a human being, failure to listen, nontherapeutic comments and questions, using leading questions, using comments that give advice, using judgmental comments, changing the subject, giving false assurance, using gossip and rumors, disruptive interpersonal behavior
Compare & contrast different communication techniques aimed at preventing communication barriers.
Complete- communicate all relevant information
Clear- convey information that is plainly understood
Brief- communicate the information in a concise manner
Timely- offer & request information in an appropriate timeframe, verify authenticity, validate/acknowledge information
Describe various types of reporting used by nurses.
SBAR: Situation, Background, Assessment, Recommendation
Check-Back: message initiated, receiver accepts message and provides feedback confirmation, sender verifies message was received.
Call out: used to communicate important/critical information like in a RRT or Code blue
Handoff: transfer of information during transitions of care
Identify essential guidelines for reporting client data.
Date and time, document ASAP, legibility and dark ink, accepted terminology, correct spelling, signature, accuracy-just the facts, sequence, appropriateness, completeness, conciseness, legal prudence
Demonstrate each form of reporting following all of the essential steps.
Source oriented record: admission face sheet, physicians orders, lab results, diagnostic test reports, history & physical, narrative notes, assessment data
Progress note: SOAP, Subjective, Objective, Assessment, Plan
Charting by exception: flow sheets
Electronic documentation
Explain HIPAA & nursing responsibilities required to maintain client confidentiality.
HIPAA is protected health information and it shouldn’t be shared with those who don’t have access, minimize is being overheard client information, don’t use a clients whole name within hearing distance of others, cover charts so not visible, never leave records unattended.
Identify & discuss guidelines for effective documentation that meets legal & ethical standards.
Close programs with information when in use, always use cover sheet when faxing PHI, never share passwords between staff, properly dispose of information containing PHI in shredding paper files, no client discussions in public areas such as elevators
Identify prohibited abbreviations, acronyms, & symbols that cannot be used in any form of clinical documentation.
U, u, IU, Q.D., QD, q.o.d., qod, trailing zero, no leading zero, MS, MSO4, MgSO4, D/C, @, >
Describe the nursing process & each of its five steps.
Assessment: systematic, continuous data collection
Diagnosis: use critical thinking skills to cluster assessment data and identify problems
Planning: client goals formulated that involves decision making, problem solving
Implementation: action phase to performs to achieve goals
Evaluation: planned, ongoing, purposeful activity to determine if client is progressing and if effectiveness of nursing plan is working.
Differentiate objective & subjective data.
Subjective: client, family
Objective: physical examination
Describe the importance of knowing when to report significant client data & of proper documentation.
Reporting client data in the right time can lead to better chances of resolving the issue and better chances of recovery for the patient
Documentation: Must be done correctly to verify everyone on the healthcare team has the option to be aware of what is going on with the patient. This information can be used to plan client care, educate staff, in research, analysis, and reimbursement/insurance purposes.
Document ASAP for accuracy and to prevent accidents
Interpret, analyze, & prioritize assessment data.
This also uses the scale of Maslow’s Hierarchy to organize the information gathered into a prioritized plan as to what needs to be done when. This is when you will want to cluster the data collected into categories of normal and abnormal and then use these findings to identify top problems.
Develop & prioritize nursing diagnoses based on Maslow’s Hierarchy of Needs.
Effectiveness: Doing the right things
Efficiency: Doing things right
Use of Maslow’s Hierarchy helps the nurse to organize clients’ needs with highest priority going to those who have needs in the bottom level of the hierarchy and working up. This helps when trying to critically decide which problem needs resolving the soonest and which problems can wait.
1. High priority: Life-threatening situations
2. Medium priority: Unhealthy physical or emotional consequences
3. Low priority: UAP can help with these problems
Develop expected outcomes & nursing interventions from the selected nursing diagnoses.
Take all data collected into consideration. These interventions should be put in place to prevent, reduce, eliminate, or improve the nursing diagnosis situation. Follow the SMART acronym when forming the patient goal. • Single specific action • Measurable • Attainable • Relevant • Time limited
Describe how the nurse would implement the plan of care.
This is where the nurse carries out what needs to be done to assist the patients in reaching the goal set for them. The entire care team must be on board for optimal implementation.
• Independent interventions: nurses licensed to initiate
• Dependent interventions: Carried out under physician’s orders, supervision
• Collaborative interventions: Reflect overlapping responsibilities of healthcare team
Evaluate the client’s response to the plan of nursing care to modify the plan as needed.
The client may be following a continuum of care when going home or may not be responding well the plan the way the nurse expected, therefore modifications need to be put in place to better tailor to the individual while still attaining the nurses purpose for the plan.
Describe the importance of knowing the generic name, classification, action, side effects/adverse reactions, dosage, route, drug interactions, and nursing implications of medications administered by the nurse.
Classification: groups of drugs that share similar characteristics
Indication: reason why medication is prescribed
Action: how medications act & type of action
Side effect: predictable & often unavoidable secondary effects produced therapeutic dose
Adverse Reaction: unintended, undesirable, often unpredictable severe responses to medications
Nursing Implications: administration recommendations, lab values relation to medication, teaching point
Describe proper documentation of medication administration in the EMAR.
Document ASAP after medication is given. Clients full name and DOB, name of medication fully written out, time, dosage, route, and frequency of administration, allergies, and injection sites
Discuss principles of medication administration, including an understanding of medication orders, importance of accurate drug dosage calculations, and medication safety measures.
Medication order: Clients name, date and time order is written, name of medication to be administered, dosage of medication, route to be administered, frequency of administration, signature of person writing the order
Medication safety measures: good communication between systems, 6 rights of administration, clarify unclear orders, have knowledge of each medication prior to administration, culture of safety
Importance of drug dosage: the correct dose is necessary because too little of a dose will not help the patient and too large of a dose can kill a patient.
Identify factors that affect safety in a person’s environment.
Developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, psychosocial state, defective equipment
Identify clients at risk for injury.
65+ years, fall history, impaired vision or sense of balance, altered gait/posture, taking diuretics or sedatives, postural hypotension
Describe nursing interventions to prevent injury to clients in healthcare settings.
Orient patient to the room, verify identify before medications and procedures, answer call lights promptly, hourly rounds
Explain how the National Patient Safety Goals promote client safety in healthcare settings.
Identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, identify patient safety risks, prevent mistakes in surgery. They promote client safety with the one goal of trying to eliminate mistakes that can lead to patient harm.
Discuss the documentation and safety checks associated with using wrist restraints.
Document date and time restraints applied, type of restraint alternatives used, notify clients family and physician. Assess for skin tears, abrasions and bruises every hour. Assess for paleness, coolness, decreased sensation, tingling, numbness, or pain inextremity
Identify alternatives to using restraints.
Bed and chair alarms, rule out agitation, involve family in care, reduce stimulation and noise/light, distract and redirect, use calm voice, simple and clear explanations/directions, night light, allow restless clients to walk, low height beds, floor mats, move room closer to nurses station.
Evaluate the effectiveness of safety interventions.
Incident report filled out when accident or incident that compromises safety happens, completed immediately after incident, do not mention report in nursing notes, notify PCP and nursing supervisor
Explore resources for developing and evaluating an emergency management plan.
National Disaster Medical System, Federal Emergency Management Agency, Centers for Disease Control & Prevention, TJC, American Red Cross, Department of Homeland Security
Discuss the importance of safe client handling and movement techniques and equipment when positioning, moving, lifting, and ambulating clients.
Use proper body alignment or posture, balance, coordinated body movement, and postural reflexes, This will help to not harm your back in the movement of patients.
Identify factors that reduce the incidence of healthcare-associated infection.
Hand hygiene, following infection control policies, sterile technique during catheter insertions, catheter care every shift for indwelling catheters, asepsis when working with central, PICC, peripheral IVs, inserting IVs, and giving injectons
Describe strategies for implementing CDC guidelines for standard and transmission-based precautions when caring for patients.
Implementation will come with enforcing the policies the facility has set. Following the protocol with help with early detection of what precaution to use for each patient and that will help to eliminate healthcare associated infections.
Summarize the physiology of comfort.
Relief of pain. Pain is the unpleasant sensory and emotional experiences associated with actual or potential tissue damage or described in terms of such damage. Pain is whatever the experiencing person says it is.
