HA- Test 1

Therapeutic communication

professional communication with clients/patients; building a trusting patient-nurse relationship

Silence

moments of silence from the nurse to allow the patient to continue talking and explaining

Reflection

repeating what the patient said in order to get more specific information; “I feel alone” ... “you feel alone?” ... “yes, I feel alone since my wife died”

Facilitation

using phrases such as “please continue” and “go on” to encourage a patient to continue their explanation

Confirmation

ensures that the nurse and the patient are on the same track and that the collected information is accurate and complete

Non-therapeutic communication

words, phrases, actions, and tones that make a patient feel uncomfortable, increase their stress, and worsen their mental and physical wellbeing

“Ten traps” of interviewing

false assurance, unwanted advice, using authority, avoidance language, distancing, professional jargon, leading or biased questions, talking too much, interrupting, using “why” questions

Verbal communication

the words spoken and the tone used in a conversation, includes written words as well

Non-verbal communication

body language, facial expressions, gestures, eye contact, etc

Empathy

ability to understand the personal experience of the patient without bonding with them; keeps a professional relationship while also calming the patients anxiety about their situation

Sympathy

not good because it focuses on the nurses’ feelings rather than the patients’

Physical environment

sit equal to the patients’ level so that they do not feel intimidated when being interviewed, provide the patient with adequate privacy, minimize distractions

Note-taking

while interviewing, keep note-taking to a minimum in order to offer full, focused attention

Purpose of health assessment

gain an understanding of the patients’ beliefs, concerns, and perception of their health state

Can compile subjective and objective data

physical appearance, posture, ability to carry on a conversation, and demeanor

Phases of an interview

introduction, working phase, and conclusion

Introduction

keep it short and formal; introduce yourself, position, and the purpose of the interview

Working phase

used to collect data, verbal skills are assessed, physical health is noted

Culture

a set of beliefs, attitudes, and practices shared by a group of people or community that is followed, accepted, and passed down to other members of the group

Spirituality

a broad term to describe one’s existence and a belief in transcendence

religion

an organized system of beliefs as a shared experience

Sexual orientation

a person’s physical and emotional interest in others (LGBTQIA+)

Gender identity

a person’s inner sensibility that they are a man, a woman, neither, etc

Gender expression

outward demonstration of gender in relation to societal norms; dress, hairstyle, mannerisms, etc

Age

older adults need to be addressed respectfully, may take longer to interview because they have a “longer” story to tell, and may use therapeutic tough to provide empathy

Disabilities

can affect the interview because communication may not be fully received

Aphasia

a communication disorder due to brain damage; sudden on-set often from stroke or head injury; impairs expression and language understanding

Broca’s Aphasia

expressive and can become easily frustrated when forming simple words/sentences; damage to area responsible for speech production

Wernicke’s Aphasia

receptive; do not understand when you speak to them; damage to the part of the brain that controls language and ability and can be very frustrating

Cultural humility

recognizing there is diversity within every culture and within every person

Stereotyping

assuming a person has attributes, traits, beliefs, and values of a cultural group because they are apart of said group

Ethnocentrism

belief that one’s culture (race, ethnicity, or country) is better than others

Discrimination

unfair and different treatment of another person/group; denying another group opportunities and rights to participate fully in society

Prejudice

unfavorable prejudgement or preconceived idea about a person or group of people

Bias

attitude, opinion or inclination (can be positive or negative) towards a group of people; can be a conscious attitude (explicit) or an unconscious attitude (implicit)

Birth to 12 months

Infants

12 to 36 months

Toddlers

3 to 6 years

Preschoolers

7 to 12 years

School-age

Beginning to puberty

Adolescents

HIPAA

Health Insurance Portability and Accountability Act

SBAR

standardized communication

Situation

brief description of pertinent patient variables, demographics, clinical diagnosis, and location

Background

pertinent history as it directly relates to patient’s current health status

Assessment

pertinent assessment findings obtained with interpretation of data

Recommendation/Request

what you need or want for the patient in terms of medical treatment and/or assistance

ABCDE

how to prioritize care/interventions

Airway

is the airway open; is the patient choking

Breathing

respiratory rate; oxygen saturation

Circulation

pulse rate and rhythm, skin color, pain, paresthesia

Disability

level of consciousness; alert and oriented?

Environment

safety, hygiene, cause of injury

Recognize Cues

identify findings that may be abnormal; document them and report to the doctor/charge nurse

Analyze Cues

relate the abnormal findings to pathophysiology; make sense of the data

Prioritize Hypothesis

what is the problem; what is causing the problem; what is the most important problem to solve

Generate Solutions

what solutions/nursing interventions/tasks/medical/management/patient education can be established

Take Action

identify what needs to be done to help the patient

Evaluate Outcomes

did the patient’s condition improve? Worsen? Unchanged?

Effective/Indicated Care

actions that are adequate to produce the intended result and help the patient

Ineffective Care

actions that are not adequate to produce the intended result; do not help the patient

Unrelated/Non-Essential Interventions

actions that will not help the patient (not better nor worse)

Contraindicated Interventions

actions that can cause more harm to the patient

First-level of Priority Care

problems/issues that reflect critical findings, clinical deterioration and/or are life-threatening; require URGENT action

Second-level of Priority Care

problems/issues that may lead to clinical deterioration and may become life-threatening without intervention; require prompt (quick) action

Third-level of Priority Care

problems/issues that are focused on functional health, client education, and counseling; should be addressed but not urgent; is not acute in nature but required to support ADLs, knowledge level, and mental health; what may be a priority to the nurse is not always a priority to the patient

Listen to your patient

this is a collection of subjective data

“Symptoms”

are what the patient describes/explains is wrong

Look (inspection), Feel (palpation and percussion), Listen (auscultate)

identifies the objective data that can potentially explain the patient’s symptoms

“Signs”

are what can be measured (vital signs, physical exam, etc)

Confirm/Validate data

use laboratory data (blood results) or other diagnostic tools (x-ray, MRI, etc)

Documentation

use an Electronic Health Record (EHR)

Emergency

rapid, life-threatening (choking, drowning, cardiac arrest)

Complete/Comprehensive

new patient, past and present history, life-style, obtain baseline VS

Focused/Problem-based

existing information, specific health concern, does not cover non-related areas

Follow-up

annual exams, mini-assessment of previous finding, improvement of previous problem

Reason for Seeking Care

the chief complaint of the patient, why they are there (nausea/vomiting, loss of appetite, insomnia, gout, swollen ankle, etc); use the PQRSTU

Provocative/Palliative

what were you doing when the pain started? What makes it better/worse? What triggers it? What relieves it? What aggravates it?

Quality/Quantity

what does it feel like? Sharp? Dull? Stabbing? Burning? Crushing? Throbbing? Shooting? Stretching?

Region/Radiation

where is the pain located? Does the pain radiate/where to? Does the pain travel? Did it begin somewhere else?

Severity

on a scale of 0-10, what is the pain? Are certain activities limited due to the pain? How bad is it at its worst? Does the pain come in waves? Do you have to stop, sit down, lie down?

Timing

when did it start? How long does it last? How often does it occur? What were you doing when it first occurred? Does it wake you up at night? Seasonal? While eating/after eating? Specific time of the day?

Understanding

do you understand why the pain occurs? Do you understand what causes it? Do you understand how to help the pain go away?

Acknowledge

greet patient by documented name, eye contact, smile, acknowledge any guests

Introduce yourself

state name, role, and reason for visiting the patient's room

Duration

estimate the time it will take to complete all tasks with the patient

Hand Hygiene

always clean hands by washing with soap and water or with alcohol-based spray/gel

Functional health

the patient’s physical and mental capacity to participate in ADLS; provides the nurse with a holistic view of a patient’s human response to illness and life conditions

ADLs

daily basic tasks that are fundamental to everyday function; walking, brushing teeth, feeding self, etc

Instrumental ADLs

more complex tasks that allow patients to function independently; managing finances, paying bills, purchasing/preparing meals, taking medications, facilitating transportation, etc

Initial screening

can show anxiety disorder or depression

Behavioral changes

memory loss, inappropriate social interactions

Brain lesions

trauma, tumor, stroke, cerebrovascular accident

Aphasia

impairment of language ability; secondary to brain damage

LOC

person is awake, alert, aware of stimuli from environment and within self; responds appropriately and quickly to stimuli

Facial expressions

appropriate and changes with topic; comfortable eye contact unless not used due to culture

Speech

quality, sounds are effortless, appropriate conversation

Mood

body language and facial expressions; mood appropriate to place and condition; person should be willing to cooperate

Posture

erect and position relaxed

Body Movements

voluntary, deliberate, coordinated, smooth and even

Dress

appropriate to setting, season, age, gender, and group

Attention Span

ability to concentrate; completes thoughts without wandering; can be impaired by people who are anxious, fatigued, or intoxicated

Recent Memory

interview question for within the past 24 hours; what one had for lunch, when they arrived at the facility; ask questions that you will know the answer to in order to match any discrepancies

Remote Memory

verifiable past events; past health, past jobs, birthday, anniversary

Immediate Recall

highly sensitive and valid memory test; pick four words and ask the patient to remember them, ask for the patient to recall the words at 5, 10, and 30 minutes - patients younger than 60 should be able to recall the four words with ease

Thought Processes

person should think logically, goal directed, coherent, and relevant; thoughts should be complete

Judgment

compare and evaluate alternatives and reach an appropriate course of action

Abstract Reasoning

use a situation in which the patient would have to apply or interpret a statement; problem solving and interpretation of analogies; applied verbally and graphically

Age

looks stated age

Sex

development for gender/age

LOC

alert and oriented

Skin color

even tone and pigmentation

Facial features

symmetric with movement

Overall appearance

presence or absence of distress

Body/posture

standing, sitting, slumped, etc

Gait

coordinated and balanced

Facial Expressions

eye contact, appropriate to situation

Behavior

appropriate to environment; Varies based on age and disabilities

Dress and hygiene

appropriate for environment, body odors, style,

Mood and affect

comfortable and cooperative with examiner

Mood

facial expressions, eye contact, what they do and what they say

Affect

outward display of one’s emotional state

Speech

ability to form words; clear and understandable; appropriate word choice to situation and culture; clear ideas

Family dynamics

hierarchy, roles, values, behaviors

Abuse

physical, emotional, mental, verbal, sexual, economic, financial

Diurnal cycle

lowest in the morning and highest in late afternoon

Exercise

increased body temperature

Stress and anxiety

increased temp due to stimulation of sympathetic nervous system and increase of epi and norepi

Menstrual cycle

causes variations due to fluctuations in hormones

Pulse Adolescent and Adult

60-100

Resp. Adolescent and Adult

12-20

BP Adult

120-140/80-90

Hypotension

low bp; caused by dehydration, bleeding, cardiac conditions, side effects of medications

Hypertension

high bp

Orthostatic Hypotension

drop in bp when moving from lying/seated position to standing; decrease in bp by at least 20mmHg systolic or 10mmHg diastolic within three minutes of standing; Can feel faint, dizzy, and lightheaded

Shock

hypotension, tachycardia, restlessness and apprehension, skin is cold, moist, pal, cyanotic, decrease in o2 sat

Nociceptive pain

develops when functioning and intact nerve fibers in the periphery and CNS are stimulated

Neuropathic pain

implies an abnormal processing of pain message that is difficult to assess and treat; perceived long after site of injury heals

Visceral

originates from larger interior organs

Deep Somatic

blood vessels, joints, tendons, muscles, and bone; Aching, throbbing, localized

Cutaneous

skin surface and subcutaneous tissues; Superficial with a sharp, burning sensation

Referred

felt at particular site but originates from another location

Acute

short-term and self-limiting

Chronic

diagnosed when pain continues for six months or longer

Breakthrough

spike in pain levels with moderate to severe intensity in an otherwise controlled pain syndrome

CRIES

postoperative pain; examines physiological and behavioral changes on 3 point scale

FLACC

nonverbal tool used to infants and children up to age 3

5 behaviors of pain

facial expressions, leg movements, activity levels, cry, and consolability