levels of communication

intrapersonal

interpersonal

group

public speaking

intrapersonal

interpersonal

public communication

forms of communication

verbal

usually conscious, spoken or written

nonverbal

often less conscious, body language, gestures

therapeutic relationship

phases of therapeutic relationship

stage 1: pre-interaction

stage 2: orientation

stage 3: working

stage 4: termination

stage 1: pre-interaction

gathering information prior to meeting client

examining own feelings/fears/anxiety about working with patient

stage 2: orientation (introductory)

creating a trusting environment

asking, "how would you like to be addressed?"

establishing expectations

gathering assessment information

identifying problems

setting goals

developing plan of care

stage 3: working

maintaining trust and rapport

problem-solving through the plan of care

remaining an active participant in the relationship

continuously evaluating progress through plan of care

clarifying feelings and concerns through verbal/nonverbal communication

stage 4: termination

concluding the relationship when (goals have been achieved, client is being discharged, rotation is over [student])

recognizing feelings about the termination of the relationship

barriers to communication

physical

perceptual (speakers)

emotional

cultural

language

gender

interpersonal (Hx w/ communicating)

barriers to communication in health care

patient/family fears

emotional control of healthcare providers

insensitivity by health care provider

sense of guilt

disagreement w/ decisions

cultural difference

personal issues

ethical concerns

components of communication

content

words, gestures, substances of message

process

sending, receiving & interpreting, reacting

therapeutic communication

techniques that assist the nurse in interacting more therapeutically w/ the clients

techniques are: client centered, goal directed

therapeutic communication techniques

using silence

observing

asking open-ended questions

encourage

clarifying

restating

reflecting

focusing

giving information

summarizing

non-therapeutic communication techniques

excessive questioning (especially yes/no ?s)

advising

agreeing

challenging

change of topic

denying

interpreting

passing judgment

reassuring

disrepectful words/tone/body language

vital signs

temperature

pulse

respiration

blood pressure (BP)

oxygen saturation

 + an assessment of pain is standard

temperature

heat produced-heat loss=body temperature

relatively narrow temperature range, 98.6°(normal for young healthy adult)-100.4°F (36°-38° C)

time of day affects temp

6am lowest-4pm highest

pyrexia(fever)- not harmful is stays below 102.2° F (adults) and 104° F (children)

pulse sites

temporal

carotid

apical

brachial

radial

ulnar

femoral

popliteal

posterial tibial

dorsalis pedis

pulse strength

+3: increase, bounding, full

+2: normal, easily palpable

+1: tready, weak, barely palpable

0: absent

pulse rates

infant: 120-160

toddler: 90-140

preschooler: 80-110

school-ager: 75-100

adolescent: 60-90

adult: 60-100

bradycardia <60

tachycardia >100

respiratory rates

newborn: 35-40

infant: 30-50

toddler: 25-32

child: 20-30

adolescent: 16-20

adult: 12-20

respiratory depth

full: full expansion of the lungs, obvious movement of rib cage

normal: relaxed, automatic and silent

shallow: small amount of air passes through the lungs

respiratory rhythm

regular: interval occurs between each respiratory cycle

irregular: periods of apnea w/ shallow and deep breathing

Blood Pressure (BP)

hypotension: systolic of <90

normal: ≤120/80

hypertension: >140/90

documentation

vital aspect of nursing practice. Anything written or printed within a patient record, may be paper, electronic or both.

provides evidence for credentialing, research, reimbursement and plan of care

necessary to reflect status of patient upon admission, transfer and discharge

confidentiality

legal and ethical obligations

HIPPA

access to electronic medical record(EMR)

multidisciplinary(all departments) communication within health care team

patient record (confidential, permanent legal documentation)

reports (oral[change of RN, telephone], written, audiotape)

purpose of records

communication

legal documentation

reimbursement

education

research

auditing and monitoring

guidelines for quality documentation and reporting

factual

accurate(exact amts & times)

complete (cover every aspect)

current (as close to time of care)

organized (be logical & have in sequence)

draw single line through errors and inital

methods of documentation

SOAP (subjective, objective, assessment, plan)

SOAPIE (subjective, objective, assessment, plan, intervention, evaluation)

PIE (problem, intervention, evaluation)

Focus charting (focus on pt concerns)

charting by exception

reduces time required to chart

uses flow sheet for assessment and interventions

narrative format for abnormal findings

narrative format for variances from interventions

used mainly in ER & critical care

common record keeping forms

admission nursing history form

flow sheets and graphic records

patient care summary (Kardex)

acuity (scale for amt of care) recording

standerized care plans

most will be obsolete once EMR takes effect

nursing informatics

informatics (science and art of turning data into information)

information technology(IT) (management and processing of information)

health care information system (HIS) (group of systems used that support and enhance health care)

principles of nutrition

digestion

absorption

metabolism

storage

nutrition is the sum of processes by which one takes in and utilizes nutrients

digestion

mouth: mastication(chewing)- amylase in saliva breaks down carbs(starches)

stomach: hydrochloric acid(HCL), lipase, and amylase (digest fats and carbs)

small intestine: digestive enzymes, including trypsin and pepsin, allows most nutrients to be absorbed (fats, carbs and protein)

large intestine: absorbs electrolytes and H2O (helps maintain fluid electrolyte balance)

absorption

small intestine(simple nutrients)

duodenum (cholesterol, vitamins E & K, folic acid, thiamin and riboflavin)

jejunum (glucose, amino acids, minerals and fats)

ileum (sucrose, maltose, and lactose)

w/diarrhea: nutrients absorption is lost. moces through small intestine too quickly to be absorbed

metabolism

all biochemical and physiological processes in the body

anabolism: production of complex substances (lipogenesis, gluconeogenesis)

catabolism: breakdown of body tissues into simpler subtances (glycolysis)

storage

energy stores

adipose tissue(fats), muscle(glycogen & protein), liver(glycogen)

essential nutrients

carbohydrates: primary source of energy

proteins: essential for body tissue growth, maintenence, and repair; energy source

lipids: carry essential fatty acids and fat soluble vitamins(a,d,e,k); energy source

vitamins: essential for normal metabolism

iron(mineral): helps blood and muscle deliver O2 to every body cell & removes carbon dioxide from cells

factors affecting nutrition

socioeconomic

physical illness

cultural

food-drug interactions

incomplete diets

nutrition risk factors: older adult

limited incomes

live alone/ no desire to cook or eat

functional limitations

chronic illness

poor oral health

taste bud atrophy

other factors affecting nutrition

obesity (66% of americans > age of 20 are overweight or obese)

malnourishment (31-33% of US pts in hospitals are considered malnourished or at nutritional risk)

nutritional screen(RN)

TJC indicates all patients are to undergo a nutritional screen within 24 hrs of admission

• diet intake Hx
• physical findings
• laboratory findings
• body mass index (BMI)

nutritional assessment (RD or nutritionist)

the following would indicate referral for nutritional assessment:

• Hx of weight loss( 10# during a 6 month period)
• current "nutritional supplement" or "modified diet" intake
• nutritional impact symptoms (chewing/swallowing difficulties, N, V, D, constipation, etc.)
• skin breakdown

signs of dysphagia(difficulty swallowing)

cough

change in voice tone or quality after swallowing

slow, weak imprecise or uncoordinated speech

abnormal gag reflex

delayed swallowing

pocketing, regurgitation

enternal nutrition

nasogastric tube(NG): nose into stomach

nasointestinal: nose into jejunum

gastrostomy: into stomach

jejunostomy: into jejunum

therapeutic diets

clear liquid

full liquid

dysphagia pureed

mechanical soft

soft/low residue

high fiber

low sodium

low cholesterol

diabetic

regular

vegetarian diets

risk for vitamin and protein deficiencies

vegetarian(red meat excluded from diet)

vegan(no animal products): risk for B12 deficiency

lacto-ovo vegetarian (like vegan but somtimes eats dairy products and eggs)

pain

an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in termss of such damage

always subjective

allodynia

pain due to a stimulus that does not normally provoke pain

ex: gentle brush of hand or fingers (fibromyalgia & migraines)

analgesia

dyesthesia

an unpleasant abnormal sensation, whether spontaneous or evoked

ex: foot falls asleep

hyperalgesia

increased pain from a stimulus that normally provokes pain

hypoalgesia

diminished pain in response to a normally painful stimulus

ex: stub toe while running(don't feel it)

hyperesthesia

increased sensitivity to stimulation(lower threshold for pain)

ex: person who is very tired may feel severe pain from a small bump into a table

hypoesthesia

decreased sensitivity to stimulation (higher threshold for pain)

nociception

the process of encoding noxious(harmful) stimuli

ex: sprains, bone fx, sunburn

nociceptors

receptors(neurons) that are capable to encode noxious (harmful) stimuli

ex: touch receptors

pain threshold

pain tolerance level

paresthesia

sensitization

somatic pain

pain receptors are activated in either the body surface or in the musculoskeletal tissues

ex: surgical sites, fx, arthritis, muscle trauma (strain)

described as dull, achy or throbbing

easy to localize

visceral pain

pain felt when internal organs are damaged

ex: organ distention, inflammation

described as aching, cramping or squeezing

difficult to localize

neuropathic pain

caused by injury or malfunction of the spinal cord or peripheral nerves

ex: diabetic neuropathy, shingles

occurs in waves of intensity and frequency

described as burning, tingling, shooting, stinging, stabbing, piercing, cutting, drilling, shocking

acute pain

comes on quickly, can be severe, but lasts a relatively short time

usually easily described and observed

chronic pain

ongoing or recurrent

lasting more than 3 months

not easily described

effects well being

can look like s/s of depression

transduction

transmission

modulation

pain-related neural impulses are dampened or amplified

gate-control theory is one explanation

perception

gate control theory

incoming pain impulses from nociceptors are modulated at a "gate" in the dorsal horn of the spinal cord

the "gate" integrates messages from the central and peripheral nervous systems

can make pain "worse" than it is. can also make pain "less" than it is 

reflex arc

SNS (sympathetic nervous system) responce to pain

involves the immediate bodily response to severe acute pain

initial response is typically helpful, but prolonged activation can be detrimental(exhaustion)

reactions are via effect on the neuroendocrine system

neuroendocrine (nerves & hormones) responses to SNS stimulation

vasoconstriction

elevation of BP

↑ HR

dilation of bronchioles

ihibition of peristalsis

inhibition of digestive enzyme secretion

neuroendocrine response to pain

hormonal response to pain

hormones ↑ in response to pain

corticotrophin-releasing hormone (CRH): ↑ BP and HR, produces behavioral responses to stress

adenocorticotropic hormone (ACTH): stimulates cortisol production

cortisol: maintains blood glucose levels, suppresses inflammatory response

adrenaline and noradrenaline: produces vasoconstriction, ↑ BP, dilates airways

glucagon: ↑ blood sugar, stimulates liver function

vasopressin: causes sodium and H2O retention by kidneys

renin & angiotensin II: promotes sodium reabsorption by kidneys, ↑ BP

growth hormone: effects metabolism or protein, carbs and fats, ↑ protein breakdown

interleukin I: ↑ coritsol release, activates inflammatory response

physiological responses to pain

cardiovascular: ↑ BP, HR, peripheral vascular resistance, oxygen consumption and risk of MI

GI: delayed gastric emptying, ↓ bowel motility, paralysis of ileum

Resp:limiting of resp muscle movement to relieve pain

Genitourinary: fluid and electrolyte imbalance

musculoskeletal: muscle spasms at pain site, impaired muscle function (↑ risk for blood clot)

immune system: poor wound healing

psychlogical responses to pain

anxiety

disrupted sleep

cognitive impairment

interference w/ ADLs

depression (w/ chronic pain)

behavioral responses to acute pain

facial grimace

fist clenching

jaw clenching

guarding of area

altered posture

moaning

withdrawal

behavioral responses to chronic pain

interferences w/ ADLs

nutrition problems

sleep problems

hygiene problems

emotional distress

social dysfunction

factors influencing pain

age

gender

culture and family

personal meaning of pain

emotional state

treatment of pain according to type of pain

somatic: NSAIDs, muscle relaxants, antispasmotics, anxiolytics

visceral: opioids, corticosteriods, anxiolytics

neuropathic: methadone, antidepressants, anti-sz, anxiolytics

non-pharmacological approaches to pain

comfort measures

heat or cold

distraction(tv, internet, visitors)

massage

guided imagery

music

biofeedback

meditation

hypnosis

prayer

etc.