Things a person tells you about that you cannot observe through your senses;
Subjective data symptoms
Objective data Information that is seen, heard, felt, or smelled by an observer; signs
Head-to-toe assessment Complete assessment of the patient, one that includes all systems
- Moisture
- Texture
- Color
- Temperature
- Turgor
What do you look for in a skin exam? - Edema
- Hair Distribution
What causes crackling during a lung exam? Excess moisture in the lungs & air sacs
Narrowing & constriction of airways
What causes wheezing during a lung exam?
What causes stridor during a lung exam? Constriction or blockage causes high-pitched sounds
What is a focused assessment? Performed to assess a specific problem/body system
- An interpretation or conclusion about a patient's needs, concerns, or health problems,
and/or the decision to take action (or not), use or modify standard approaches, or
improvise new ones as deemed appropriate by the patient's response
- Thinking like a nurse
- RN decides what data is to be collected, interprets data, arrives at a nursing
Clinical judgement diagnosis and identifies appropriate nursing actions
Primary prevention Efforts to prevent an injury or illness from ever occurring
- Braden scale
- Exercise
Examples of primary prevention - Nutrition
- Hydration
Secondary prevention Screening to reduce the impact of a disease or injury that's already occurred
- ABCDE skin exam
- Mammogram
Examples of secondary prevention - Colonoscopy
Braden scale Tool for predicting pressure ulcer risk
Principles of right and wrong that guide an individual in making decisions which is
Ethics influenced by families, beliefs, values and ideas
Cultural awareness Knowledge, experience with, and respect for various cultural beliefs and values
- An understanding of how a patient's cultural background shapes his beliefs, values,
and expectations for therapy
- Ability to interact effectively with people of different cultures
- Cultural desire: wanting to understand differences
- Self awareness: identify and understand own identity
Cultural competence - Knowledge: expose self to other cultures be motivated to learn
- Skill: acquired throughout time and using therapeutic communication
- The process by which racial or ethnic groups are absorbed into the dominant group
by adopting the dominant group's culture
Cultural assimilation - Minority group loses cultural identity
, A widely held but fixed and oversimplified image or idea of a particular type of person
Stereotype or thing
Stigma Usually attached to people with certain conditions
Prejudice Preconceived opinion that is not based on reason or actual experience
Effective communication competence Achieved when communication goals are met
Communication has been adapted to the people and situation involved in the act of
Appropriate communication communication
- Personal bias
- Stereotypes
Barriers of communication - Stigmas
- Optimizing safety and health care quality
Communication competence is important for - Advocacy for better systems and safer workplaces
- Assertive
- Therapeutic
- Intrapersonal
- Interpersonal
Exemplars of communication - Documentation
- Handoff/reporting (SBAR)
- Positive and negative feelings expressed openly/directly
Assertive communication - Helps advocate for the patient
- Interactive process, words/actions used by clinicians and patients
- Helps patient overcome temporary stress
- Helps patient adjust to difficult situations
Therapeutic communication - Promotes understanding and builds relationships that lead to positive patient
outcomes
Intrapersonal communication Self-talk
- Between people
- Talking among
Interpersonal communication - Verbal/nonverbal
- Begins at birth
Documentation Legal documents
SBAR
- Situation
- Background
Handoff reporting - Assessment
- Recommendations
- Process of interaction using symbols to create, exchange and interpret messages
- Learned skill develops over time
Communication - Complementary exchange: sender transmitting a message to receiver
- Development of partnerships to achieve best possible outcomes that reflect the
particular needs of a patient
Collaboration - Key component in reducing errors
- Begins on admission
Subjective data symptoms
Objective data Information that is seen, heard, felt, or smelled by an observer; signs
Head-to-toe assessment Complete assessment of the patient, one that includes all systems
- Moisture
- Texture
- Color
- Temperature
- Turgor
What do you look for in a skin exam? - Edema
- Hair Distribution
What causes crackling during a lung exam? Excess moisture in the lungs & air sacs
Narrowing & constriction of airways
What causes wheezing during a lung exam?
What causes stridor during a lung exam? Constriction or blockage causes high-pitched sounds
What is a focused assessment? Performed to assess a specific problem/body system
- An interpretation or conclusion about a patient's needs, concerns, or health problems,
and/or the decision to take action (or not), use or modify standard approaches, or
improvise new ones as deemed appropriate by the patient's response
- Thinking like a nurse
- RN decides what data is to be collected, interprets data, arrives at a nursing
Clinical judgement diagnosis and identifies appropriate nursing actions
Primary prevention Efforts to prevent an injury or illness from ever occurring
- Braden scale
- Exercise
Examples of primary prevention - Nutrition
- Hydration
Secondary prevention Screening to reduce the impact of a disease or injury that's already occurred
- ABCDE skin exam
- Mammogram
Examples of secondary prevention - Colonoscopy
Braden scale Tool for predicting pressure ulcer risk
Principles of right and wrong that guide an individual in making decisions which is
Ethics influenced by families, beliefs, values and ideas
Cultural awareness Knowledge, experience with, and respect for various cultural beliefs and values
- An understanding of how a patient's cultural background shapes his beliefs, values,
and expectations for therapy
- Ability to interact effectively with people of different cultures
- Cultural desire: wanting to understand differences
- Self awareness: identify and understand own identity
Cultural competence - Knowledge: expose self to other cultures be motivated to learn
- Skill: acquired throughout time and using therapeutic communication
- The process by which racial or ethnic groups are absorbed into the dominant group
by adopting the dominant group's culture
Cultural assimilation - Minority group loses cultural identity
, A widely held but fixed and oversimplified image or idea of a particular type of person
Stereotype or thing
Stigma Usually attached to people with certain conditions
Prejudice Preconceived opinion that is not based on reason or actual experience
Effective communication competence Achieved when communication goals are met
Communication has been adapted to the people and situation involved in the act of
Appropriate communication communication
- Personal bias
- Stereotypes
Barriers of communication - Stigmas
- Optimizing safety and health care quality
Communication competence is important for - Advocacy for better systems and safer workplaces
- Assertive
- Therapeutic
- Intrapersonal
- Interpersonal
Exemplars of communication - Documentation
- Handoff/reporting (SBAR)
- Positive and negative feelings expressed openly/directly
Assertive communication - Helps advocate for the patient
- Interactive process, words/actions used by clinicians and patients
- Helps patient overcome temporary stress
- Helps patient adjust to difficult situations
Therapeutic communication - Promotes understanding and builds relationships that lead to positive patient
outcomes
Intrapersonal communication Self-talk
- Between people
- Talking among
Interpersonal communication - Verbal/nonverbal
- Begins at birth
Documentation Legal documents
SBAR
- Situation
- Background
Handoff reporting - Assessment
- Recommendations
- Process of interaction using symbols to create, exchange and interpret messages
- Learned skill develops over time
Communication - Complementary exchange: sender transmitting a message to receiver
- Development of partnerships to achieve best possible outcomes that reflect the
particular needs of a patient
Collaboration - Key component in reducing errors
- Begins on admission
