Documentation/Communication/Client Education

• Sender (encoder)
• Message
• Receiver (decoder)
• Response

• self talk, happens within an individual
• Ex. "Calm down, you can handle this"

• Between 2+ people with goal of exchanging message
• ex. nurse talking with patient about outcome goals

• nurses interact w/2+ individuals
• staff meeting, pt care conference, teaching session, support group

• something almost spiritual/aura
• Not concrete or tangible
• More like unseen inner energy
• Spiritual motivation, inspiration, encouragement

• large, formal setting
• council meeting
• committee meeting

• (spoken words or cues)
• Patient states “I feel nauseated”

• (sight, observations and perceptions)
• nonverbal cues: furrowed brow, flushed face, pursed lips lead to perceived message of anger

• (touch)
• squeeze of shoulder, rub back conveys message of comfort

• members value and "own" the aims of the group
• aims are clearly articulated

• members generally trust and like one another
• loyalty to the group
• high commitment
• high degree of cooperation

• Honest
• Direct communication flows freely
• Members support, prain, and critique one another

• problems are identified
• appropriate method of decision making is used (i.e. indiv, minority, majority, consensus, unanimous)
• decision is implemented and followed through
• group commitment to decision is high

members feel strong sense of responsibility for group outcomes

effective style of leadership to meet desired aims

• Sources of power are recognized and used appropriately
• needs or interest of those with little power are considered

• using words, either spoken/written
• depends on language
• (interactions with patient and family, giving oral reports to other nurses, writing care plans, charting progress, composing signs and posters)

• transmitting without use of words
• often body language: subtle and hidden meanings behing verbal statement
• generally more accurate when there in an incongruence
• (touch, eye contact, facial expressions, posture, gait, gestures, general physical appearance, mode of dress/grooming, sounds, silence)

looking at all the information needed before you meet with the patient

• Appropriate range can be anywhere from 18in-4ft, depending on the nonverbal cues picked up by the nurse
• Nurse mst be sensitive to the offensiveness of many interventions within close proximity and show always ask permission/warn the patient
• Social Zones: hands, arms, shoulders, back
• Personal Zones: (1) mouth and feet (2) face, neck, front of body (3) genitalia (most personal)

• introductions
• roles are clarified
• agreements made about goals of relationship
• location/frequency/length of contacts
• duration of relationship
• includes orientation to facility and environment

• work together to meet patient’s physical and psychological needs
• nurse provides whatever assistance is needed
• sentiments and feelings about people affect cooperativeness
• roles of teach and counselor take place

• when conclusion of initial agreement is acknowledged
• participation in identifying goals accomplished or progress made
• verbalized feelings about termination of relationship

• identifying with the way a person feels
• nurse is sensitive to patient feeling but objective enough to provide the care needed

feeling of mutual trust experienced by people in a satisfactory relationship

• can be contentedness
• reflection
• efense/fear mechanism
• display of anger
• filled with excessive talking

• active participation
• open body posture
• facing patient without crossed arms/legs
• eye contact as appropriate
• nonverbal cues given and received

for comfort or with appropriateness during care

as a healing strategy and positive interpersonal interaction

• allows for wide range of responses
• "How does that make you feel?"

• yes or no
• specific answer
• used appropriately or it becomes a barrier
• "What medicines have you been taking at home?"

• validate what nurse believes she is hearing
• "At home you've been taking a water pill and a blood pressure pill. Have you taken them today?"

• gain understanding of a comment
• Pt: "I have never needed medicine before."
• Nurse: "Is this the first health problem you've ever had?"

• repeating to promote elaboration
• pt: "I've been really upset about my blood pressure."
• nurse: "You've been upset..."

• chronological order to find a possible cause and effect relationship
• "Your tiredness began after you started taking your medicine?"

• returning to an earlier topic or introducing a new aspect
• tactfully and repectfully
• "You mentioned your dad earlier. Did he develop complications related to blood pressure?"

• open, honest, direct communication
• 1. Empathy: "I guess it must be hard for you to balance this workload while taking care of your family at home"
• 2. Description: "I must be honest in that I’m feeling so overwhelmed with this workload that I sometimes experience signs of high anxiety"
• 3. Expectation: "I understand this program requires a vigilant work ethic, but I might need some help with time management skills"
• 4. Consequences: "I expect to overcome this feeling, but I fear I won’t be prepared to provide safe and
• adequate patient care"

• Failure to perceive patient as a human being (not a diagnosis or dysfunction)
• Failure to listen (nurse may focus on nurse’s needs, not patient’s need)
• Inappropriate comments and questions (clichés, yes/no, why/how, probing, leading questions [lead to nurse’s desired response], comments of advice, judgmental comments)
• Changing the subject
• Giving false assurance
• Gossip and rumor (hinders group building and teamwork)
• Aggressive Interpersonal Behavior (horizontal violence- nurse to nurse hostility, anger and aggressive behavior between nurses, bully/blame/criticize/bicker)

• stereotyped, trite, pat answer
• suggest no cause for anxiety or concern
• offer false assurance
• "everything will be alright"
• "don't worry"

• "Did you have a good day?"
• cut the discussion of

• intimidating, accusing
• "Why weren't you tired enough to sleep?

• getting the "third degree", interrogation
• pt usually stops talking, avoids further conversation

• suggest what response the speaker wishes to hear
• unlikely to get an honest answer without feeling indimidated
• "You're going to smoke that cigarette, aren't you?"

• implies that the nurse knows what's best for the patient
• denies patient the right to make decisions and have feelings

• impose the nurse's standards on the patient
• "You aren't acting very grown up. You shouldn't be crying like a child."

• Aphasia: varies is degree of inability to understand others’ words, express self, or be understood
• Hearing Problems: (presbycusis- loss by aging) can’t hear, or can hear but can’t understand
• Dysarthria: abnormal control of speech mechanism (several contributing diseases)
• Voice Problems: (larygenctomy- must learn esophygeal speech via electronic device or surgical prosthesis) most can be treated
• Others: brain diseases affecting brain cognitive function

• acknowledge presence
• identify self
• normal tone
• explain reasons for touch
• indication termination
• keep call light close
• orient to environment and sounds
• keep glasses clean

• orient patient to your presence
• talk directly to patient
• facing them and maintain positive nonverbal communication
• demonstrate procedures
• sign language
• write it down
• keep ear aids clean and functioning

• select means of communication through blink/hand squeeze/writing on board
• assure everyone communicates with patient
• assure effective means of signaling for assistance

• be careful of what is said (they might be able to hear you)
• assume patient can hear you
• speak before touching
• quiet low volume environmental surroundings

• interpreter
• dictionary translation
• simple sentences with normal tone
• demonstrate ideas
• maintain positive nvb communication

• Promote Health: develop specific health practices idiosyncratic to that patient to promote wellness
• Prevent Illness: (many forms) making home environment safe, counsel those at risk for disease, disease prevention or early detection
• Restore Health: self-care practices to promote recovery with no complicationsFacilitate
• Coping: patient and family adjustment/acceptance of lifestyle changes/illness

• As person matures, self-concept is likely to move form dependent to independent
• previous experiences are a rich resource for learning
• readiness to learn is often r/t a developmental task/social role
• material should be useful immediately, rather than at some time in the future

• Motivation: very important to process of learning, greatly affected by patient’s health beliefs model
• Ability: note factors—age/development, cognitive ability, do they understand? (same language/able to communicate)
• Environment: support of family members or lack thereof, long-term caregivers as part of learning process, financial resources; any limitations

• (storing/recalling new knowledge in brain)
• acquisition
• comprehension
• application
• analysis

• (changes in attitudes, values, feelings)
• chooses
• displays
• initiates
• revises
• values

• (learning physical skill)
• integration of mental and muscular activity
• demonstrates
• shows
• manipulates
• creates

• recommend lifestyle change
• provide appropriate information

• identify willingness
• discuss pro/con
• examine barriers
• explore motivators
• alternatives

• set a start date
• outline plan/strategy
• discuss potential problems
• strategy to overcome them
• negotiate achievable plan
• use of support systems
• discuss potential for relapse

• identify helpful parts
• revise/reset if needed
• make schedule for periodic contact/follow-up

• identify triggers
• discuss and re-evaluate motivation
• revisit counseling steps for precontemplation and contemplation
• additional referrals if needed

• It is the only permanent legal document that details nurse’s interactions with patients
• Best defense for nurse if patient alleges nursing negligence
• Communication
• Education
• Quality of care reviewing
• Diagnostic and therapeutic orders
• Research
• Decision analysis
• Care planning
• Reimbursement
• Legal and historical documentaion

each healthcare group keeps data on its own separate form

address routine care, normal findings, and patient problems identified in plan of care

• organized around problems rather than sources of info
• defined database
• problem list
• care plans
• progress notes

• Subjective data
• Objective data
• Assessment
• Plan
• (SOAPIER):
• Intervention
• Evaluation
• Response

• Problem
• Intervention
• Evaluation
• Unique: does not develop a separate plan of care
• uses pre-printed flow sheets to complete assessment at beginning of each shift
• plan of care is incorporated into progress notes, in which problems are identified by number

• brings focus of care back to patient an patient concerns
• holistic
• may be patient concern/behavior, therapy/response, change in condition, significant events

• Data: "Pt states pain in right rib area"
• Action: "Tylenol 3 admin'd as ordered"
• Response: "Pt reports relief from pain"
• Narrative portion of focus charting

only significant findings or “exceptions” to standards of practice are documented in narrative notes

clearly identify outcomes that select groups of patients are expected to achieve on each day of care

• (computerized)
• integrates pathways and documentation flow sheets designed to match each day’s expected outcomes to event
• discharge planning

• (patient fails to meet outcomes)
• chart unexpected event, cause of event, actions taken in response

• Nursing care elements (nrsg dx + intrvn)
• Pt Demographic elements (sex, DOB, ethnicity)
• Service elements (admin/discharge dates, expected payer for services)

any variety of methods of notes that relate how a pt is progressing toward expected outcomes

• graphic rcord of abbreviated aspects of patient's condition
• (eg. vital signs, routine aspects of care)

• records specific patient variables
• (pulse, respiratory rate, blood pressure readings, body temp, weight, fluid intake and output, bowel movements)

intake and output

• documentation of all meds administers
• nurse administering drug
• sometimes reason for administration

ability to rank patients in high to low acuity

information necessary for immediate care to patient

OASIS: Outcome and Assessment Information Set

• RAI: Resident Assessment Instrument
• (minimum data set, triggers, resident assessment protocols, utilization guidelines)

each patient summary and status information

enable nurses to receive and give critical information about patients quickly and easily

concisely summarize all the patient data that caregivers need to provide immediate care

anything out of the ordinary that results in or has potential to result I harm to patient, employee, or visitor

• clients have rights to access records and see exactly what you wrote
• (important to you use quoted responses and not judgments about the client)
• protocols to each agency/setting determine how client access is achieved
• client can consent who can see the chart, who can know that they are there

• Long-Term/Short-Term
• Motivational
• Specialized
• interpersonal process of helping pts to make decisoins that promote overall well-being