Foundations of Nursing Practice: Assessment and Communication

Evidence based practice - Described as combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patients’ values and circumstances The holistic health model assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together COLLECTING 4 TYPES OF DATA I. Complete total health database- complete health history and full physical examination II. Episodic or problem-centered database- for limited or short term problems - Concerns mainly 1 problem; ex: sore throat III. Follow up database- evaluates the status of any identified problem at regular intervals to follow up on short-term and chronic health problems IV. Emergency database- rapid collection of crucial data, which often occurs while performing lifesaving measures PRIORITIES: ● First-level priority problems are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing ● Second-level priority problems are next in urgency. They require prompt intervention to prevent further deterioration and may include mental status change, acute pain, or abnormal laboratory values in the patient. ● Third-level priority problems are important to the patient’s health but can be addressed after more urgent problems. Examples include lack of knowledge or family coping. ● Collaborative problems are certain physiologic conditions in which the approach to treatment involves multiple disciplines. The Nursing Process ASSESSMENT: - Should be evidence based - Subjective data + objective data + patient’s record DIAGNOSIS: - Interpretation of the data by identifying clusters of cues so as to make inferences - Compare clusters of cues with definitions and defining characteristics - Validation of inferences based on findings - Identifying related factors - Document the diagnosis OUTCOME IDENTIFICATION: - Identify goals - Realistic and measurable; give a time and date - Short term or long term? PLANNING: - Establish priorities based on meeting identified pt care goals - Develop outcomes and set time frames for meeting proposed goals - Document plan of care IMPLEMENTATION: - Determine pt readiness and involve them in care - Include other health care members in plan of care→ collaborative effort EVALUATION: - Summarize the results - Did they meet their goal/s? - Modify plan of care if needed Nursing Diagnosis Medical diagnosis= describes disease/illness/injury→ focuses on etiology Nursing diagnosis= statement of client health that nurses can identify, prevent, or treat→ actual or potential problems TYPES OF NURSING DIAGNOSIS ★ Risk- may or may not happen, but vulnerable ★ Actual- problem response at the time of assessment; signs and symptoms ★ Wellness- in transition from one level of wellness to a higher level ★ Possible- suspect a diagnosis is present but not enough data ★ Syndrome- collaborative NANDA NURSING DIAGNOSIS: COMPONENTS: ➔ Diagnostic label ➔ Definition ➔ Defining characteristics ➔ Related factors ➔ Risk factors WRITING A DIAGNOSIS - Include problem and etiology→ “problem” related to…. “Etiology” (“manifested” by) USING ROY’S MODEL ★ Assessment of behavior ○ Maladaptive or adaptive ○ Cognator or regulator ★ Assessment of stimuli ○ Focal- immediate cause of problem ○ Contextual- contributory cause of problem ★ ★ ★ ★ ○ Residual- unknown cause contributing to problem Write the nursing diagnosis Set goal Interventions Evaluation Communication and the Interview PHASES OF THE THERAPEUTIC RELATIONSHIP ★ Pre-interaction phase- setup environment/room for interview to take place; review pt chart if they have a previous one ★ Orientation phase- introduction ★ Working phase- gather data ★ Termination phase- introduce that the interview is over; any final last concerns or questions BARRIERS TO THERAPEUTIC COMMUNICATION ● Asking too many questions ● Changing the subject ● Asking why questions ● Failing to probe→ asking more questions to get desired information ● Expressing approval or disappointment ● Offering advice ● Providing false reassurance ● Stereotyping ● Using patronizing language 9 TYPES OF VERBAL RESPONSES Patient’s Perspective: 1) Facilitation→ encourages patient to say more 2) Silence→ wait for response 3) Reflection→ echoes words 4) Empathy→ names feeling and allows expression 5) Clarification→ summarizes words Examiner’s Perspective: 6) Confrontation→ inconsistencies 7) Interpretation→ inferences 8) Explanation→ sharing factual info. 9) Summary→ condenses facts 10 TRAPS OF INTERVIEWING 1) Providing false assurance or reassurance 2) Giving unwanted advice 3) Using authority 4) Using avoidance language 5) Engaging in distancing 6) Using professional jargon 7) Using leading or biased questions 8) Talking too much 9) Interrupting 10) And using “why” questions 7 NONVERBAL MODES OF COMMUNICATION 1) Posture 2) Gestures 3) Physical appearance 4) Eye contact 5) Touch 6) Voice 7) Facial expressions INTERVIEWING THE OLDER ADULT ➔ When interviewing the older person, be alert for expressions of hopelessness or despair about the patient’s present life or the future. Always address the person by his or her last name, such as “Hello, Mr. Simmons.” Adjust the pace of the interview to the older person; it may take longer for an older person to tell his or her story, or the person may require a longer response time. Do not hurry the interview along. Consider that physical limitations may cause the older person to fatigue earlier. Consider that hearing impairment may exist, and be sure to face the person fully and avoid shouting. Touch may be a helpful nonverbal skill that is important to older persons and may convey an empathetic message. INTERVIEWING PEOPLE WITH SPECIAL NEEDS Hearing Imparied: Those who are hearing impaired might require a hearing aid or clearance to see the examiner’s lips under sufficient light that is not too blinding. Do not exaggerate words for they can come off wrong, speak in a clear tone. Do not yell at these patients...repeat yourself if necessary Acutely Ill: do not extend interview..ask closed questions because client is in pain and cannot communicate effectively Under the influence: Simple and direct questions and reexamine them when they are no longer affected - C: cut off - A: annoyed - G: guilty - E: eye opener Personal questions: do not feel obligated to answer..people can be trying to make advances Sexually aggressive people: inform them upon a strict professional relationship...ask them to stop...tell them you feel uncomfortable..ask someone else to take over care...report the issue Crying: encourage crying...not every time a patient cries means it’s because of you because the topic might be emotionally sensitive and can bring up baggage or issues a patient has...reflect upon their sadness if they seem sad and provide a safe space for them to let out feelings Anger: never turn your back on these patients...keep a calm and collected voice...do not raise your voice back...do not address why they are angry but let them talk and LISTEN...call for backup if things cannot be handled Acts of violence: Approach them calmly and safety is always your #1 priority so care for yourself first Anxiety: appear unhurried and listen to the patient and let them talk about their fears USING AN INTERPRETER - For a patient with limited English proficiency or hearing impaired, use a sign language interpreter or a bilingual team member or a trained medical interpreter whenever possible. Avoid using a family member or close friend as an interpreter because this violates the patient’s confidentiality and they may edit or change the message. - If an interpreter is not available, there are 24 hour interpreter hotlines that can be helpful...speak in a clear tone and the interview might have to be concise with just important information SBAR Situation Background Assessment Recommendations THE COMPLETE HEALTH HISTORY - Biographical data - Name, age, address, birthday, phone number Source of information (reliability) - Who are you getting the information from? Reason for seeking care Present health or history of present illness - - PQRSTU Symptoms analysis Past health events Family history Review of systems Functional assessment Adolescent health history: - H ome environment - E ducation - E ating - A ctivities - D rugs - S exuality - S uicide - S afety