W1 Nurse Notes Flashcards
WHAT ARE SOME OF THE TASKS CERTIFIED NURSING ASSISTANTS (CNA’s) CANNOT PERFORM?
-Give medication
-Put/irrigate nasogastric tube
-Blood Draw
-Diagnose/Interpret results of vitals (ex. Informing patient whether vital result is good or bad)write down in the do you know that right
-Performing nail care to feet for patients with specific orders
-Insert foley catheter
-Starting Feeding Tubes
types of communication
-Dynamic- conversation between nurse and patient back and forth.
-Ongoing
-Unique
Intrapersonal vs Interpersonal Communication
-IntRApersonal: “self-talk”
IntERpersonal: most common form in nursing
functional components
Referent: motivates one person to communicate with another
Sender
Receiver
Message
Channel
Environment
Feedback
Interpersonal Variables
methods of communication
verbal
nonverbal
electronic
what is therapeutic communication
Interactive, purposeful
Use of the Nursing Process: Assessment, Diagnosis, Planning, Implementation, Evaluation
Nursing Process : ADPIE
-assess: gather info about the patient’s condition
-diagnose: identify the patient’s problems
-plan: set goals of care and desired outcomes and identify appropriate nursing actions
-implement: perform the nursing actions identified in planning
-evaluate: determine if goals and expected outcomes are achieved
nursing process
ASSESSMENT
* Verbal interviewing and history taking
* Visual and intuitive observation of nonverbal behavior
* Visual, tactile, and auditory data gathering during physical examination
* Written medical records, diagnostic tests, and literature review
NURSING DIAGONSIS
* Intrapersonal analysis of assessment findings
* Validation of health care needs and priorities via verbal discussion with patient
* Documentation of nursing diagnosis
PLANNING
* Interpersonal or small-group health care team planning sessions
* Interpersonal collaboration with patient and family to determine implementation methods
* Written documentation of expected outcomes
* Written or verbal referral to health care team members
IMPLEMENTATION
* Delegation and verbal discussion with health care team
* Verbal, visual, auditory, and tactile health teaching activities
* Provision of support via therapeutic communication techniques
* Contact with other health resources
* Written documentation of patient’s progress in medical record
EVALUATION
* Acquisition of verbal and nonverbal feedback
* Comparison of actual and expected outcomes
* Identification of factors affecting outcomes
* Modification and update of care plan
* Verbal and/or written explanation of care plan revisions to patient
Draw the interpersonal variables
Phases of helping relationship
Preinteraction phase
Orientation phase
Working phase
SBAR
used for communicating critical information improves the perception of communication and information about patients among health care providers
-Situation, Background, Assessment, Recommendation
SURETY model for active listening
Sitting facing the patient
Uncrosses legs and arms
Relax
Eye contact
Touch
Your intuition
why is patient hygiene important
effect on overall health
-varies with social, cultural, and daily routines of the patient
hygiene map
-Knowledge Base: Anatomy and physiology of integument, oral cavity, and sensory organs; normal Range of joint motion; principles of caring, comfort, and safety; communication principles; risk factors causing hygiene issues; knowledge of cultural variations in hygiene; and effects of patient’s illness or injury on hygiene needs and ability to perform hygiene measures.
-Environment: Impact of medical devices on time and task complexity, resources for other therapies (for example physical therapy and additional personnel), and interruptions in care.
-Experience: Prior experience caring for patients requiring assistance with hygiene, personal hygiene practices, and skill competence in hygiene care
-Standards: ANA standards and scope of nursing practice, clinical practice guidelines and standards of practice
-Attitudes: Display curiosity, be thorough in assessing patient; display humility, hygiene care should be patient centered, know when to learn more about patient’s preferences.
Three concentric levels of hygiene
-Clinical decision making.
-Recognize cues and analyze cues (interconnected), prioritize hypotheses and generate solutions (interconnected), and take actions and evaluate outcomes (interconnected).
-Assessment, analysis or diagnosis, planning, implementation, and evaluation.
