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Unit 3
| Question | Answer |
|---|---|
| Nurses use communication skills to: | 1. Gather data 2. Teach others 3. Comfort others 4. Build a working relationship with colleagues and patients |
| When communication is effective | a ‘message’ is sent, received and understood, and validated to the sender via feedback. |
| Therapeutic communication | * Promote wellness and growth * Transfers the decision-making to the patient * Make the communication patient-centered * Ensure that the communication is goal-directed * Limit personal information during the exchange |
| techniques facilitate communication | * Open-ended questions * Closed-ended questions * Focused questions * Sharing observations * Paraphrasing * Reflecting * Clarifying * Summarizing * Validating |
| techniques that can have therapeutic effects | * Silence * Nonverbal behaviors such as touch, gestures, body position, eye contact * Awareness and respect for cultural and language differences |
| helping relationship | three phases: * Orientation Phase * Working Phase * Termination Phase |
| patient record | * Nursing Histories * Education Records * Nursing/Progress Notes * Entries on flow sheets * Entries on medication administration records |
| Examples of reports | * Change-of-shift report * Transfer reports * Incident reports |
| patient's record is a legal document | purposes--they are: * Communication * Legal documentation * Financial * Education * Research * Auditing and Monitoring |
| types of record systems | source record and the problem-oriented medical record. |
| formats for recording patient data: | * Narrative notes * SOAP (IE) notes * PIE notes * Focus (DAR) notes * Charting by exception(CBE) * Critical pathways |
| complete nursing/progress note includes: | Assessment data Interventions performed Evaluation |
| SOAP | Subj.data/Obj.data/Assessm./Plan. It is used to organize data interies in POMR (problem oriented medical records.) |
| PIE | Problem/Intervention/Evaluation. Unique charting system because it does not develop separate plan of care. Documented in the beginning of the each shift using the flow sheets. |
| DAR | Data/Action/Response. Narrative portion of the focus charting, principle advantage is holistic emphasis on the Pt and Pt's priority. |
| CBE | Charting/by/exception. Shorthand documentation method. Benefits are decrease charting time, easy retrieval of data, timely bedside charting, standardize assessment, tracking of Pt response and lower cost. |
| Flow Sheets | documentation tool used to record routine aspects of nursing care. |
Created by:
russianalaskan
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