Foundations Chapter 20: Communicator & Chapter 16: Documenting, Reporting & Informatics

The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement made by the newly hired nurse would indicate to the nurse educator that intervention is needed? "You are scheduled for surgery 4 hours from now" "I will need to draw blood from you before the operation." "Do you have any questions about your cholecystectomy?" "Can you remove your ring or do you need help?"

"Do you have any questions about your cholecystectomy?" The nurse should be careful to use lay terminology when speaking with clients unless the nurse knows the client is a health care professional. The client may not understand what a cholecystectomy is. The other questions are appropriate and the client should be able to understand them.

A hospital patient has been on call for the operating room (OR) since early this morning and has been NPO (fasting) since midnight. It is now 3:30 PM and there has been no call from the OR as yet. During the nursing student's most recent time in the patient's room, the patient muttered a curse and alluded to the fact that he feels miserable and hungry. What response by the student best demonstrates empathy? "Can I get you some gum to chew on perhaps?" "It must be frustrating for you to lie there hungry while you 'hurry up and wait.'" "I know how you feel. I missed my scheduled lunch break yesterday" "Try and feel how much better you'll feel when get to finally have your surgery"

"It must be frustrating for you to lie there hungry while you 'hurry up and wait.'" Saying "It must be frustrating for you to lie there hungry while you 'hurry up and wait'" acknowledges and validates the patient's feelings while leaving it open for him to elaborate if he so chooses. Offering gum may be helpful but does not explicitly acknowledge the patient's current reality.

The client is talking to the nurse about recent health problems of immediate family members and the strain she has been under trying to care for them. She begins to cry between sentences. What response by the nurse demonstrates the most empathy?

"Just take your time. I am listening." This response allows the client to collect her thoughts while also expressing emotion, and it lets the client know the nurse is there for her. Using appropriate periods of silence rather than "talking away" the client's feelings is empathetic. "I know how you feel" does not focus on the client's feelings. Stating "It's okay to cry" or "Take some time for yourself" are statements that indicate the need for the client to seek approval in order to experience her own feelings.

collaborative pathways

-(may also be called critical pathways or care maps) are used in the case management model. The collaborative pathway specifies the plan of care linked to expected outcomes along a timeline -In some documentation systems, the collaborative pathway is part of a computerized documentation system that integrates the collaborative pathway and documentation flow sheets designed to match each day's expected outcomes.

The Outcome and Assessment Information Set, or OASIS, is a group of data elements that:

-Represent core items of a comprehensive assessment for an adult home care patient -Form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI) -The OASIS is a key component of Medicare's partnership with the home care industry to foster and monitor improved home health care outcomes

focus charting

-The purpose of focus charting is to bring the focus of care back to the patient and the patient's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a patient and patient care. -narrative portion of focus charting uses the Data, Action, Response (DAR) format -principal advantage of focus charting is the holistic emphasis on the patient and the patient's priorities

charting by exception

-a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes -provides quick access to abnormal findings as it does not describe normal and routine information -frequently used with collaborative pathway documentation systems

PIE charting

-unique in that it does not develop a separate plan of care -the plan of care is incorporated into the progress notes, which identify problems by number (in the order they are identified) -patient assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets) -Patient problems identified in these assessments are numbered, documented in the progress notes, worked up using the Problem, Intervention, Evaluation (PIE) format, and evaluated each shift -has a nursing origin

A nurse is working on a medical-surgical unit with an experienced licensed practical/vocational nurse (LPN/LVN). Which tasks are appropriate to delegate to the LPN/LVN? (Select all that apply.) Teach a client with diabetes how to administer insulin. Administer oral aspirin and lisinopril to the client with hypertension. Reinforce a post-surgical abdominal dressing. Insert a nasogastric tube in a client with absent bowel sounds. Change an intravenous catheter for a client.

Administer oral aspirin and lisinopril to the client with hypertension. Reinforce a post-surgical abdominal dressing. Insert a nasogastric tube in a client with absent bowel sounds. Administration of oral medication, insertion of nasogastric tubes, and dressing changes are all within the scope of practice for a LPN/LVN. Teaching and insertion of intravenous catheter is not in the current scope of practice for a LPN/LVN.

A nurse is planning care for an adult client with severe hearing impairment and a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care?

Arrange for an interpreter when discussing treatment. During the planning step of the nursing process the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. A sign language interpreter allows the client to participate fully in the plan of care. Consulting with the client's children is not as beneficial because it places them in the difficult position of translating while experiencing the emotional strain of the parent's illness. A TTD/TTY line can assist in communication, but is not as helpful as a medical interpreter.

What ensures continuity of care? Communication Reassessment Critical thinking Integration

Communication Communication ensures continuity of care and provides essential data for revision or continuation of care.

What is the primary purpose of the client record?

Communication The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another

Which is not a purpose of the patient care record? Contract Reimbursement Legal Document Care Planning

Contract Explanation: Patient care records are legal documents, communication tools, and assessment tools. They are used for care planning purposes, quality assurance purposes, for reimbursement, research, and education.

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

Empathy The nurse should empathize with the family for their loss. Empathy helps the nurse to provide effective care and support without being emotionally distraught by the family's condition. If the nurse becomes indifferent to the family's condition, the nurse may not be able to assess their needs. The nurse should not pity, or provide sympathy to, the family for their loss, as it would involve the nurse emotionally.

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?

Graphic sheets The graphic record is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics. Flow sheets are documentation tools used to efficiently record routine aspects of nursing care, not data as asked in the question. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few items.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident report An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed. Verbal orders should only be accepted during an emergency. No other action is correct other than asking the health care provider to write the order.

The nurse observing an interaction between a mother and her daughter appropriately identifies the interaction as which communication zone?

Intimate The interaction between parents and children is likely to occur in the intimate zone. The distance between close friends who are interacting is the personal zone. The distance when interacting with acquaintances is the social zone. The public zone occurs when communicating with an audience or small group.

Flow sheets are used to document patient status on a geriatric subacute unit. The student nurse's assessment of a long-term patient reveals a marked decline in the patient's level of consciousness compared with recent baselines. What is the student's best response?

Note this on the flow sheet and make an entry in the narrative progress notes. In settings where the flow sheet is the primary documentation form, narrative progress notes are supplementary. The interdisciplinary care team should be made aware of this change in status and it should be noted in the progress notes. Protocol may or may not permit the nurse to unilaterally begin a neurological flow sheet; regardless, doing so will not inform the interdisciplinary team. "Focused charting sheets" are not appended to flow sheets

A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques? -Open-ended -Validating -Closed -Reflective

Open-ended question The nurse's question allows for a wide range of responses and encourages free verbalization, characteristics of a useful open-ended question. Validating questions allow the nurse to confirm what was previously said, while closed questions necessitate a "yes" or "no" answer. A reflective question or comment repeats what the client has recently said.

The student nurse has entered a patient's room and noted that the patient is grimacing and guarding her left flank. What action will the student next perform during the perception process?

Organizing the observed behaviors During the perception process, stimuli (such as a patient's nonverbal behaviours) are first selected and then organized. This organization precedes interpretation, comparison, and drafting a response.

Which principle should guide the nurse's documentation of entries on the client's health care record? Documentation does not include photographs. Precise measurements should be used rather than approximations. Correcting fluid is used rather than erasing errors. Nurses should not refer to the names of physicians.

Precise measurements should be used rather than approximations. Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians, and photographs can constitute documentation. Handwritten entries should be struck through with a single line, not covered with correcting fluid or erased.

A nurse documents the following client data in the patient record according to the SOAP format: Client reports unrelieved pain; client is seen clutching the side and grimacing; client pain medication does not appear to be effective; Call in to primary care provider to increase dosage of pain medication or change prescription. This is an example of what charting method?

Problem-oriented method The problem-oriented method is organized around a client's problems rather than around sources of information. With this method, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care. Progress notes clearly focus on client problems.

Which scenario is an example of using patient records for quality assurance purposes? -Data are gathered from groups of records to determine significant similarities in disease presentation, to identify contributing factors, or to determine the effectiveness of therapies. -Records are randomly selected to determine whether certain standards of care were met and documented. -The nurse considers all data on the patient's record when developing goals, outcome criteria, interventions, and evaluation criteria to and for the patients. -The patient record is used by a student to learn how a certain disease may present itself.

Records are randomly selected to determine whether certain standards of care were met and documented. Quality assurance is when records are randomly selected to determine whether certain standards of care were met and documented. Care planning is when the nurse considers all data on the patient record when developing, goals, outcome criteria, interventions, and evaluation criteria for and with patients. Research is performed when data are gathered from groups of records to determine significant similarities in disease presentation, to identify contributing factors, or to determine the effectiveness of therapies. The medical record can be used for educational purposes such as when it is used, by a student, to learn how a disease might present itself in certain patients.

How can the nurse researcher obtain information from a client record?

Study client records. Nursing and health care research is often carried out by studying client records.

What does the nurse recognize as purposes of the electronic health record?

The electronic health record provides an avenue to document continuity of care, qualify healthcare providers for government funds, ensure client safety and facilitate health education and research. It can provide evidence during practice lawsuits, however, that is not the purpose of the electronic health record.

What information should the nurse document in the medication record when administering a non-narcotic pain medication?

The nurse should document the medication given, time, route, dose, reason given, and effectiveness of the medication on the medication administration record.

acuity records

Twenty-four-hour reports are increasingly used in conjunction with acuity reports, with which nurses rank patients as high-to-low acuity in relation to both the patient's condition and need for nursing assistance or intervention. A trauma patient whose condition is changing rapidly and who requires intensive nurse monitoring and intervention merits a higher acuity rank than a patient whose condition is stable. Acuity rankings are often used to determine staffing requirements

A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?

Write a narrative note in the designated nursing section. Source-oriented records have separate sections for each discipline to document their own information. Therefore, the nurse would not document in the respiratory section or find the lab results under the physician section. Critical pathways are not used to document physical assessments.

graphic form

a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics

Characteristics of effective documentation

accessible, accurate, relevant, consistent, auditable, clear, concise, and complete, legible/readable, thoughtful, timely, contemporaneous, and sequential, and retrievable on a permanent basis

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult

an audiologist A nurse who suspects a speech, language, or hearing problem should refer the client to a speech-language pathologist or audiologist. A speech-language pathologist is a professional educated in the study of human communication, its development, and its disorders. An audiologist is a professional educated in the study of normal and impaired hearing. An ophthalmologist is a medical doctor who specializes in the treatment of eye disorders. An optometrist has a practice doctorate and focuses on vision. A clinical psychologist is a behavioral health expert

health information exchange

an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient's vital medical information

An older adult client who has had a colostomy for over 10 years states, "I won't need any teaching about colostomies. I understand how to change the bag and care for my colostomy, but I'm not sure how to best clean my stoma." What does this statement indicate?

an incongruent relationship The client's two statements are incongruent with each other. This indicates the need for further education.

A nurse is on his lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. The nurse recognizes one of the physicians as being in charge of his clients. The nurse witnesses the physician point at the nurse and state, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address any disrespectful remarks or behaviors. When disruptive physician behavior occurs, it is best to respond assertively and confront the physician directly. If this is not possible, ask to speak to the physician in private and address any disrespectful remarks or behaviors. Nurses should factually document the occurrence of any bullying behaviors and speak to a nurse-manager if the behavior continues.

collaborative pathway

case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

The nurse caring for a client with a recent head injury asks the client to raise his left arm as high as possible. The client repeatedly raises his right arm. What does this indicate?

difficulty with decoding messages Decoding refers to the receiver of communication being able to understand the sender's message.

flow sheets

documentation tools used to efficiently record routine aspects of nursing care; well-designed flow sheets enable nurses to quickly document the routine aspects of care that promote patient goal achievement, safety, and well-being

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

have group members confront the dominant member to promote the needed team work

The term metacommunication is best defined as:

interpersonal bridge between verbal and nonverbal communication. Metacommunication is a communication about the client's communication or lack thereof. It is an implicit, but integral, part of the message and is an interpersonal bridge between the verbal and nonverbal components of communication.

The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining:

objectivity. Directly quoting statements made by the client can help in maintaining objectivity.

A nurse is working as a case manager and audits charts. Audits of client records are performed primarily for quality assurance and:

reimbursement

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out?

reviewing health changes During the termination phase of the nurse-client relationship, the nurse and the client review health changes and how the client has dealt with physical and emotional responses. During the orientation phase of the nurse-client relationship, the nurse and client work toward establishing trust and rapport. During the working phase of the nurse-client relationship, the nurse attends to the physical health care needs and develops solutions that are acted upon by the client.