Coping, stress, and adaptation/Nursing health history and assessment/nursing process

Therappeutic communication
-a learned skill (unnatural)
-focuses on client

Types of communication
-written
-verbal
-non-verbal
-metacommunication

Written communication
documentation, instructions for procedures, medication information, s bar notes (ways to communicate with healthcare providers), different societies

Verbal communication
Talking between people, giving report

Non-verbal communication
One of the most important types of communication.

Congruence
Make sure that verbal and nonverbal communications match. Can be gestures, posture, facial expressions, distance, appearance

Metacommunication
Communication about communication. Critical thinking about communication, intrapersonal communication about the communication process

Interpersonal communication
communication between 2 people

Intrapersonal communication
communication with yourself (self thoughts)

Transpersonal communication
communication with spiritual self/could be prayer

Verbal communication
-vocabulary (need to be cautious–avoid medical jargon)
-pacing
-intonation (tone of voice says a lot)
-clarity and brevity (don’t sugar coat, get to the point, avoid small details)
-timing and relevance (make sure timing is appropriate especially when explaining medians, procedures, etc.)

Non-verbal communication
-personal appearance
-posture and gait
-facial expression
-eye contact
-gestures
-territoriality and personal space

Zones of personal space
-intimate zone: 0-18 in
-personal zone: 18 in-4 ft
-social zone: 4 to 12 ft
-public zone 12 ft and beyond

The communication process: elements
-sender
-encoding
-communication channel
-receiver
-decode
-feedback

Factors effecting communication
-altered sensory perception
-language
-personal history (culture, parenting, experience, etc.)

Noise
anything that distracts the communication process

Dysphagia
gag

dysphasia
speech

wernicke
receptive trouble. Can’t understand what someone is saying, having trouble receiving communication

Broca
expressing trouble. Know what you want to say, but can’t say it. Comes out broken.

Nurse-client relationship phases
-orientation (establish trust/rapport)
-working (develop and implement solutions to concerns and evaluate interventions)
-termination (closure of relationship)
*go through every phase every time you walk into patient’s room
*should be talking about termination during orientation phase (giving patient time frame on how long interaction will last)
*teaching termination during beginning of interation

Empathy
not showing emotions but feeling for the person in that situation

Nursing diagnoses
signs and symptoms of disorder. Ex: pain, impaired verbal communication, anxiety, powerlessness

Therapeutic communication techniques
-offering self
-open ended questions (give patient best opportunity to explain more than just one word response)
-active listening
-restatement
-reflection
-giving information (allowed to give information but cannot give advice
-silence
-appropriate humor
*IF DNR CCO: can only do modalities to help with pain/comfort–cannot give CPR, electric shock, or intubation

Non-therapeutic communication techniques
-rescue feelings/codependency (nurses are there to help, not there to rescue patients)
-false reassurance (can only state facts)
-giving advice
-sharing personal opinions
-changing subject
-being moralistic
-asking for explanations
-non-professional involvement

Defense mechanisms
-compensation
-conversion (repression of anxiety, unconsciously transforming anxiety into non-organic symptom–ex: loss of appetite)
-denial
-displacement
-suppression
-repression (not trying to not think about it–subconscious just does not believe it happened)
-identification
-projection
-regression
-sublimation (having urges to walk around naked, but instead writes songs about it)

Conceptual frame works of nursing
what is in and outside of nursing

nursing theory
link the conceptual frameworks

Florence nightingale
-founder of modern nursing
-began nursing research during the Crimean War (noticed relationship between environment and health
-Theory of sick nursing vs. well nursing (primary, secondary, tertiary)

Primary
disease prevention: immunization, hand washing, wearing seatbelt, fluoride in water, etc.

Secondary
early detection and treatment: going for annual checkups

Tertiary
trying to get patient back to “well” at the highest level possible:rehab, recovery, post surgery phase

Dorthea Dix
Established the Nurse Corps of the United States Army

Clara Barton
Organized American Red Cross

Skill acquisition in nursing education
-novice
-advance beginner
-competent

Noive
-governed by established rules
-behavior is limited and inflexible due to lack of knowledge
-textbook: black and white

Advanced beginnner
-Exhibit marginally acceptable performance
-principles to guide actions begin to be formulated
-principles are based on experience
-start to form own theories and thoughts, task checklist based

Competent
-begins following 2-3 years of nursing practice
-conscious deliberate planning to achieve organization and efficiency

Proficient
Good at what you do

Expert
-uses intuition and psychological and social aspects as well

4 constructs to a nursing theory
1. nursing
2. person
3. health
4. environment

Nightingale
-concentrated on environment
-addressed sick nursing vs. well nursing
-health/hygiene and how the environment effects health

Peplau
-concentrated on interpersonal interaction
-interaction between the nurse and patient, patient and doctor, doctor and nurse
-patients functions cooperatively with nurses and doctors (patient has most important voice

Henderson
-concentrated on client/patient independence
-nature of nursing
-getting patient as independent as possible
-believed you couldn’t be physically well if you weren’t psychologically well

Rogers
-concentrated on unitary man/energy fields
-believed in energy fields
-could see an aura in patients and the energy they were giving off
-nursing is not just science, it is also an art
-thought that person is more than just a sum of their parts

Orem
-concentrated on self-care
-getting patient to take care of themselves
-said there were 3 interacting systems

King
-humans are constantly interacting with their environments:
1. personal
2. interpersonal
3. social

Neuman
-systems
-adopted King’s systems
-said that most important is stress and how you react (coping)
-focused on distress and how to help patient cope

Roy
-adaptation theory
-built on King and Neuman’s systems
-took Neuman’s ideas on stress and coping and added adaptation to it (changing their belief system/make a lifestyle change)

Watson
-caring
-got back to the route of it all
-not just treating disease/illness, but need to care for them
-caring is essential to nursing

Parse
-man-living-health unity
-pushed quality of life vs. quantity of life

General systems theory
-sum is greater than all of its parts
-holistic approach

Maslow’s hierarchy of needs
-physiological needs (Basic needs:food, water, warmth, rest)
-safety needs (basic needs: security and safety)
-belongingness and love needs (psychological: intimate relationships, friends)
-esteem needs (psychological:prestige and feeling of accomplishment)
-self-actualization (self-fulfillment needs: achieving one’s full potential, including creative activities)
**physiological needs are most important

Lewin’s change theory
-unfreezing
-movement
-refreezing

ABCs
-Airway
-Breathing
-Compressions
*Except for CPR: CAB

Health history
-family history
-previous surgeries
-medications
-etc.

Gene history
-family medical history
-parents
-grandparents
-siblings
-children

physical assessment
-getting hands on patient
1. Inspection
2. Percussion
3. Palpation
4. Auscultation

Inspection
looking for abnormalities

Percussion
listening for residence (bone vs. fatty tissue)

Palpation
induration (hardness and raised)

Auscultation
listening (usually use stethoscope)

Abdominal assessment
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
*Order is changed because when you press down on abdomen you can change the rate of bowel sounds

Purpose of health assessment
-establish database of client’s abilities (baseline data)
-compare assessment findings with medical diagnosis to decide if more data is needed
-organize into systems (cardiac, etc.): use Gordon’s function health patterns (FHP)
-Head to toe assessment

Functional assessment
Gordon’s functional health patterns (FHP)

Head to toe
organized manner, head to toe

Body systems assessment
focus on specific body systems

Primary data
-information from the client
*if patient is in coma/non responsive–you cannot get primary data. Patient is only person who can give you primary data!

Secondary data
-information from other than the client
-usually collect secondary data first

Culture (health assessment)
the nurse’s unconscious biases may influence data

Assess health perception
client’s perspective of their health status

assessment of activity and exercise
-posture
-gait and balance
-decreased mobility (not always muscular and skeletal: often times COPD)

assessment of nutrition and metabolism
dietary habits and metabolism

Obtaining subjective data
-assessment of elimination
-assessment of rest and sleep
-assessment of cognition and perception
-assessment of self-perception and self-concept
-assessment of roles and relationships
-assessment of coping and stress
-assessment of sexuality and reproduction
-assessment of values and beliefs

clinical manifestations
subjective + objective data

Normal urine output (times per day)
5-7 times per day

Normal urine output each elimination
200-300ml (1500ml/day)

Minimum urine output per day
720 ml excreted per day
30ml/hr
240ml/8 hour shift

Renal failure due to decreased output
when kidneys produce less than 400ml/day

oliguria
insufficient urine production

polyuria
too much urine production

frequency
going to the bathroom often

Alert and oriented x4
1. name
2. place
3. time
4. why
*can use colloquialisms

obtaining objective data: physical examination
-use of senses to obtain information about the client’s ability to function
-positioning (draping helps ensure privacy)
-inspection, palpation, percussion, auscultation
-general survey (overall appearance of the client)

Insepction
-physical observations of the client
-looking for symmetry
-with elders and young children thermoregulation is important–especially while washing!

Palpation
-using hands, touch to gather data
-finger tips are good to indicate texture changes
-palms of hand are good for tactile vibration
-dorsal of hand good for temperature

Percussion
-tapping of an area of the client’s body to produce sound

Auscultation
use of stethoscope to hear sounds in the client’s body

Newborn and infant considerations
-keep covered
-involve parents
-keep covered-loose heat fast especially through the head

Toddler and preschooler considerations
-involve parents
-explain in simple terms

School age child and adolescent considerations
-proper draping
-honest answers to questions
-be cautious with therapeutic touch since touching at this age is iffy

Adult and older adult considerations
-prepare client for all procedures
-provide privacy
-older clients can be chilled easily
-make accommodations for limitations in flexibility

Nursing process
-Systematic problem solving approach designed to address the needs of individual patients, families, and communities
-5 steps: Assessment, diagnosis, planning, implementation, evaluation

Assessment
-Gathering data: signs and symptoms, and then organizing the data
-primary and secondary data

Diagnosis
-Identifying problem and prioritizing problems
-Client centered
-Nurses cannot diagnose diseases, but can say “at risk for…”

NANDA
North American Nursing Diagnosis Association
– addresses the need for common language/goals for all nurses
-are endorsed by ANA

ANA
American Nurses Association
-lobby on nurses behalf
-have code of ethics

3 types of nursing diagnosis
1. Actual
2. Risk for
3. Wellness

Actual nursing diagnosis
1. diagnosis
2. related to (R/T)
3. as evidence by (AEB)

Risk for nursing diagnosis
1. diagnosis
2. R/T
*Avoid medical diagnosis, if you must, add “second to” before diagnosis

NOC
-code for nursing interventions and outcomes to medically bill patient

Outcome criteria/goals
makes sure they are:
-measurable
-realistic
-client centered

Planning
Identify nursing strategies to:
-direct care, promote continuity of care, focus charting
-provide for delegation of specific patient care activities
-Nursing Intervention Classification (NIC)

Implementation
-Actual initiation of identified interventions and care activities
-Types: direct, indirect, cognitive, interpersonal, technical
-Reassess if needed, set priorities, perform nursing interventions, record and document nursing interventions

Direct care measures
-ADLs
-Physical care techniques
-Counseling
-Teaching
-Controlling for adverse reactions
-Preventive measures

Indirect Care measures
-Communicating nursing interventions
-delegating, supervising, and evaluating the work of other staff members

Evaluation
-review patient goals and determine if expected outcome criteria were met/achieved (collect data to identify patient’s response to interventions, measure goals/outcome achievement)
-document degrees of goal attainment
-terminate, continue, or revise/modify plan of care

Outcome evaluation
met, not met, partially met

Process evaluation
-have to evaluate process if goal was not met

Care plan revisions
-discontinue
-modify: reassess, nursing diagnosis, client goals and outcomes, and nursing intervention

1. When formulating a definition of “health,” the nurse should consider that health, within its current definition, is: 1. The absence of disease 2. A function of the physiological state 3. The ability to pursue activities of daily living 4. …

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? Glucose level After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion …

1. Which item below correctly describes the U.S. Bureau of Labor Statistics predictions by 2020? a. Positions that historically required registered nurses will be filled by unlicensed personnel. b. The job growth rate for RNs will surpass job growth in …

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client’s tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. …

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