Comfort/Pain, Communication, Documentation Flashcards Preview

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Flashcards in Comfort/Pain, Communication, Documentation Deck (26)
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1
Q

Pain truths?

A

Pain is universal, the most common reason for seeking medical care, subjective and highly individualized.

2
Q

Origins of pain?

A

Cutaneous, superficial, visceral, deep somatic, radiating, referred, phantom, psychogenic

3
Q

Acute pain?

Duration, purpose, pattern?

A

Short lived, under six months, transient. Purpose is warning that something is wrong. Pattern is self limited and readily alleviated

4
Q

Acute pain?

Localization, clinical signs, prognosis?

A

Localization is generally well confined and identified. Signs are high BP, HR, R ( sympathetic activity. Initial physiologic response. Prognosis is good once the underlying problem is resolved.

5
Q

Chronic pain?

Duration, purpose, pattern?

A

Longer than six months. Somethings happening in the body. Pattern can be continuous or intermittent, intensity varies.

6
Q

Chronic pain?

Localization, clinical signs, prognosis?

A

Localization is well define and indistinct. Signs, the body adapts, vital resume to the norm, and pain does not decrease. Prognosis is that complete relief is not possible.

7
Q

When to assess for pain?

A

During each initial shift assessment. Before and after every procedure or treatment that’s potentially painful. Before and after pain intervention per facility policy. With every vital check. With every report of pain.

8
Q

What to asses for pain?

PQRST

A
Provoking-precipitating factors
Quality, what it feels like
Region/radiation-location
Severity-intensity
Time-onset, duration, frequency
9
Q

What do nurses with expert communication skills do?

A

Express caring, take initiative, believe nurse-client relationship is equal to partnership, appreciate uniqueness, include patient/family/cultural consideration, use critical thinking

10
Q

What are the levels of communication?

A
Intrapersonal: self talk
Interpersonal: between two people
Small group: small number of people
Public: with an audience
Electronic: technology
11
Q

Explain the circular transition model of communication

A

Referent, sender, receiver, message channels, feedback, interpersonal variables, environment

12
Q

Phases of the helping relationship?

A

Preinteraction, orientation, working, termination

13
Q

Possible nursing diagnoses for communication?

A

Anxiety, social isolation, ineffective coping, compromised family coping, powerlessness, impaired social interaction, impaired verbal communication

14
Q

Active listening SOLER?

A
Sit facing the patient
Observe an open posture
Lean toward the patient
Establish and maintain intermittent eye contact
Relax
15
Q

What is documentation and what does it do?

A

Record of proof for authorized persons, either paper or electronic. Reflects the quality of care. Provides evidence of each health care team member’s accountability in giving care.

16
Q

What are the legal guidelines for recording?

A

Correct all errors promptly. Record all facts, no personal opinions. Do not leave any blank spaces in notes. Write in black ink. Chart only for yourself. Avoid generalizations. Keep pw secure.

17
Q

What makes up quality documentation?

A

Factual, accurate, complete, current, organized

18
Q

Paper documentation

A

Episode-oriented. Key information may be lost from one episode of care to the next.

19
Q

Electronic health record (EHR)

A

Digital version of a patient’s medical record. Integrates all of a patient’s information in one record. Improves the continuity of care.

20
Q

Problem-oriented medical record?

A

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21
Q

SOAP
PIE
DAR

A

Subjectivem objective, assessment, plan
Problem, intervention, evaluation
Data, action, response

22
Q

Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.

A

Admission nursing history form

23
Q

Help team members quickly see patient trends over time and decrease time spent on writing narrative notes

A

Flow sheets and graphic records

24
Q

Includes meds, diet, community resources, follow-up care, emergency contacts. Recorded as discharge teaching.

A

Discharge summary forms

25
Q

Occurs with the transfer of patient care. Provides continuity and individualized care. Quick and efficient.

A

Hand-off report.

26
Q

I-SBAR or SBAR

A
Introduction
Situation
Background
Assessment
Recommendation