NURSE-3101 Lecture Notes - Lecture 7: Mental Status Examination, Vital Signs, Joint Commission

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Published on 20 Sep 2016
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Chapter 20 Communicator
Significance of Issue
60% of all sentinel events are caused by ineffective communication. (JCAHO, 2005).
80% of serious medical errors occur due to miscommunication between caregivers when
patients are handed off or transferred. (Joint Commission, 2012, text p. 458).
Social Media: ANA Principles for Social Networking
Don’t transmit or place online individually identifiable patient information.
Observe ethical patient-nurse boundaries.
Patients, colleagues, institutions, employers may view postings.
Separate personal and professional information online.
Bring content harmful to patient privacy/rights/welfare to attention of appropriate
authorities.
Participate in developing institutional policy.
Teamwork and Collaboration
Nurses must function effectively within nursing and within inter-professional teams,
fostering open communication, mutual respect, and shared decision-making to achieve
quality patient care.
Hand-Off Communication SBAR Technique
Accurate presentation and acceptance of patient-related information from one RN to
another.
Hand-off communication to/from:
oOther hospital departments.
oNurse-to-nurse.
oNurse-to-physician.
oNurse to outside facility (another hospital or a nursing home).
SBAR
oSituation
oBackground
oAssessment
oRecommendations
SBAR
S (SITUATION):
oWho you are calling about
oCode status
“The problem I am calling about is. . .”
oVital signs
Temp, pulse, respiratory rate, BP
oAny other significant findings
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Oxygen saturation or urine output
B (BACKGROUND):
oSignificant facts of patient history
Relevant past history; similar occurrence; surgery; etc.
oMental status
oSkin and extremities
oUse of oxygen and current oxygen saturation
oRelevant findings from your physical assessment
Lung congestion, chest pain, bleeding, appearance of surgical incision,
patient report of pain, absence of bowel sounds, etc.
A (ASSESSMENT):
o“This is what I think the problem is.”
o“The problem seems to be infection/respiratory/cardiac/neurologic.”
o“I’m not sure what the problem is but the patient is deteriorating.”
o“The patient seems to be unstable and may get worse, we need to do something.”
oI always told the doctor, “This patient looks bad to me!”
R (RECOMMENDATION):
o“We need to transfer the patient to ICU.”
o“You need to come to see the patient right now!”
oWhat new tests need to be ordered? CBC? BMP? ABGs? CXR? ECG?
oIf a change in treatment is ordered by the doctor—“When would you want us to
call you back?”
Helping (Therapeutic) Relationship
For specific purpose with specific person.
Patient shares info on health problems; nurse shares info related to professional role.
The helping (therapeutic) relationship is built on the patient’s needs, not on those of the
helping person (nurse).
Helping (therapeutic) relationships are professional relationships.
Identify nurse models who, through their appearance, demeanor, and behavior,
communicate a clear sense of professionalism.
Helping Relationship--Phases
ORIENTATION
oIntroduction by name; establish goals; orient patient to what will happen.
WORKING
oNurse works together with patient to meet patient needs.
TERMINATION
oAcknowledge conclusion of helping relationship (transfer to another division or
end of shift). Tell patient who will care for them next.
Create a Helping (Therapeutic) Relationship
TRAITS OF THE NURSE:
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oWarmth, friendliness.
oOpenness, respect.
oEmpathy: identifying with the way another person feels.
oHonesty, authenticity, and trust.
oCaring.
oCompetence (evaluate your own strengths/weaknesses).
Listening Skills
If possible, sit when communicating with patient.
oBe alert; take your time.
oMaintain eye contact (if this is culturally appropriate).
Indicate you are paying attention to what patient is saying by facial expressions and
gestures.
oNod your head; say, “Go on” or “Yes, I see.”
Listen for themes in patient comments.
oBe quiet and listen to what patient is saying. You don’t have to talk.
Interviewing Techniques
Open-ended question
oEncourages free verbalization; gets them talking.
Closed question
oGathers specific information; allows focus on a particular area.
Validating or clarifying question
Reflecting question
oTrying to describe patient’s feelings; “you’ve been upset. . .”
Patient as Team Member
Listen to patients.
Involve them in their care.
Identify patient concerns before beginning to provide them with information.
Speak in clear terms they can understand.
Provide patient and family with information.
Ask patient and family for feedback.
Encourage patient and family to be an active member of the team.
Call-Out
Used to inform team of critical information at the same time (for example, in an
emergency).
It helps everyone to be on the same page.
Helps team to anticipate next steps.
Helps you to recognize when you need help.
Check-Back
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