1-Differentiate between the use of an interpreter and a translator when performing an
assessment with a non-English speaking patient.
There is a difference between an interpreter and a translator. An interpreter is more likely
to unconsciously try to make sense of (interpret) what the patient is saying and therefore
inserts his or her own understanding of the situation into the database. A professional
translator, on the other hand, tries to avoid interpreting. DeAngelis (2010) strongly advises
against the use of untrained interpreters such as family members, friends, and neighbors.
These individuals might censor or omit certain content (e.g. profanity, psychotic thoughts,
and sexual topics) due to fear or a desire to protect the patient. They can also make
subjective interpretations based on their own feelings, share confidential details with
outsiders, or leave out traumatic topics because they hit too close to home for them.
For patients who do not speak English or have language difficulties, federal law mandates
the use of a trained translator (Arnold & Boggs, 2011). In fact, Poole and Higgo state that
the "use of a trained translator is essential wherever the patient's first language is not
spoken English (even where the person has some English)" (2006, p. 135). A professionally
trained translator is proficient in both English and the patient's spoken language, maintains
confidentiality, and follows specific guidelines. Unfortunately, professional translators are
not always readily available in many health care facilities.
2-Explain three principles a nurse follows in planning actions to reach agreed-upon outcome
criteria.
Assessment
Assessment is the first step and involves critical thinking skills and data collection;
subjective and objective. Subjective data involves verbal statements from the patient or
caregiver. Objective data is measurable, tangible data such as vital signs, intake and
output, and height and weight.
Data may come from the patient directly or from primary caregivers who may or may not be
direct relation family members. Friends can play a role in data collection. Electronic health
records may populate data in and assist in assessment.
Critical thinking skills are essential to assessment, thus the need for concept-based
curriculum changes.
Diagnosis
The formulation of a nursing diagnosis by employing clinical judgment assists in the
planning and implementation of patient care.
The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to
date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the part of the
patient, family or community.
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and
plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a
hierarchy based on basic fundamental needs innate for all individuals. Basic physiological
needs/goals must be met before higher needs/goals can be achieved such as self-esteem
and self-actualization. Physiological and safety needs provide the basis for the
implementation of nursing care and nursing interventions. Thus, they are at the base of
Maslow's pyramid, laying the foundation for physical and emotional health.[4][5]
Maslow's Hierarchy of Needs
,Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway
(suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC's),
sleep, sex, shelter, and exercise.
Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide
precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and
safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart
disease).
Love and Belonging: Foster supportive relationships, methods to avoid social isolation
(bullying), employ active listening techniques, therapeutic communication, sexual intimacy.
Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of
control or empowerment, accepting one's physical appearance or body habitus.
Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point
of view of others, reaching one's maximum potential.
Planning
The planning stage is where goals and outcomes are formulated that directly impact patient
care based on EDP guidelines. These patient-specific goals and the attainment of such
assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal
setting. Care plans provide a course of direction for personalized care tailored to an
individual's unique needs. Overall condition and comorbid conditions play a role in the
construction of a care plan. Care plans enhance communication, documentation,
reimbursement, and continuity of care across the healthcare continuum.
Goals should be:
Specific
Measurable or Meaningful
Attainable or Action-Oriented
Realistic or Results-Oriented
Timely or Time-Oriented
3-As you begin the assessment process, Mr. R stops you and says, "I don't know why you need
to do an assessment; I am just here to get my medicines adjusted."How would you respond to
Mr. S? Just listen to the patient what is his concern and go through an assessment before
adjusting drugs, keep good report, check vitals, mental status, and other risk factors.
What is the purpose of a psychiatric mental health nursing assessment? To establish rapport,
review physical and mental status; assess risk factors, formulate care plan.
CHAPTER 8:
1- Explain the three phases of the nurse-patient relationship?
Three Phases of Nurse-Client Relationship:
Orientation Stage
Establishing therapeutic environment.
The roles, goals, rules and limitations of the relationship are defined, nurse gains
trust of the client, and the mode of communication are acceptable for both nurse and
patient is set.
o Acceptance is the foundation of all therapeutic relationship
o Acceptance of others requires acceptance of self first.
Rapport is built by demonstrating acceptance and non-judgmental attitude.
, Acceptance of patient means encouraging the patient verbally and non-verbally to
express both positive and negative feelings even if these are divergent from
accepted norms and general viewpoint.
o The nurse can encourage the client to share his/her feelings by making the
client understand that no feeling is wrong.
Trust of patient is gained by being consistent.
Assessment of the client is made by obtaining data from primary and secondary
sources.
The patient set the pace of the relationship.
During this phase, the problems are not yet been resolved but the client's feelings
especially anxiety is reduced, by using palliative measures, to enable the client to
relax enough to talk about his distressing feelings and thoughts.
This stage progresses well when the nurses show empathy provide support to client
and temporary structure until the client can control his own feelings and behavior.
o Reality testing - is accepting the patient's perceptions, feelings and thoughts
as neither right nor wrong, but at the same time offering other options or
points of view to the client in a non-argumentative manner for the purpose of
helping the client arrive at more realistic conclusions.
o To provide structure is to intervene when the client loses control of his own
feelings and behaviors by medications, offering self, restrain, seclusion and
by assisting client to observe a consistent daily schedule.
Working/ Exploration/ Identification Stage - at this point, the client's problems are
identified and solutions are explored, applied and evaluated.
The focus of the assessment and of the relationship is the client's behavior and the
focus of the interaction is the client's feelings.
The nurse should realize that the client's feelings of security are developed by being
consistent at all times.
Perception of reality, coping mechanisms and support systems are identified.
The nurse assists the patient to develop coping skills, positive self concept and
independence in order to change the behavior of the client to one that is adaptive
and appropriate.
o The nurse uses the techniques of communication and assumes different
roles to help the client.
Termination/ Resolution stage
the nurse terminates the relationship when the mutually agreed goals are met, the
patient is discharged or transferred or the rotation is finished. The focus of this stage
is the growth that has occurred in the client and the nurse helps the patient to
become independent and responsible in making his own decisions. The relationship
and the growth or change that has occurred in both the nurse and the patient is
summarized.
Client may become anxious and react with increased dependence, hostility and
withdrawal, these are normal reactions and are signs of separation anxiety, these
feelings and behavior should be discussed with the client.
assessment with a non-English speaking patient.
There is a difference between an interpreter and a translator. An interpreter is more likely
to unconsciously try to make sense of (interpret) what the patient is saying and therefore
inserts his or her own understanding of the situation into the database. A professional
translator, on the other hand, tries to avoid interpreting. DeAngelis (2010) strongly advises
against the use of untrained interpreters such as family members, friends, and neighbors.
These individuals might censor or omit certain content (e.g. profanity, psychotic thoughts,
and sexual topics) due to fear or a desire to protect the patient. They can also make
subjective interpretations based on their own feelings, share confidential details with
outsiders, or leave out traumatic topics because they hit too close to home for them.
For patients who do not speak English or have language difficulties, federal law mandates
the use of a trained translator (Arnold & Boggs, 2011). In fact, Poole and Higgo state that
the "use of a trained translator is essential wherever the patient's first language is not
spoken English (even where the person has some English)" (2006, p. 135). A professionally
trained translator is proficient in both English and the patient's spoken language, maintains
confidentiality, and follows specific guidelines. Unfortunately, professional translators are
not always readily available in many health care facilities.
2-Explain three principles a nurse follows in planning actions to reach agreed-upon outcome
criteria.
Assessment
Assessment is the first step and involves critical thinking skills and data collection;
subjective and objective. Subjective data involves verbal statements from the patient or
caregiver. Objective data is measurable, tangible data such as vital signs, intake and
output, and height and weight.
Data may come from the patient directly or from primary caregivers who may or may not be
direct relation family members. Friends can play a role in data collection. Electronic health
records may populate data in and assist in assessment.
Critical thinking skills are essential to assessment, thus the need for concept-based
curriculum changes.
Diagnosis
The formulation of a nursing diagnosis by employing clinical judgment assists in the
planning and implementation of patient care.
The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to
date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the part of the
patient, family or community.
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and
plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a
hierarchy based on basic fundamental needs innate for all individuals. Basic physiological
needs/goals must be met before higher needs/goals can be achieved such as self-esteem
and self-actualization. Physiological and safety needs provide the basis for the
implementation of nursing care and nursing interventions. Thus, they are at the base of
Maslow's pyramid, laying the foundation for physical and emotional health.[4][5]
Maslow's Hierarchy of Needs
,Basic Physiological needs: Nutrition (water and food), elimination (Toileting), airway
(suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABC's),
sleep, sex, shelter, and exercise.
Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide
precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and
safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart
disease).
Love and Belonging: Foster supportive relationships, methods to avoid social isolation
(bullying), employ active listening techniques, therapeutic communication, sexual intimacy.
Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of
control or empowerment, accepting one's physical appearance or body habitus.
Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point
of view of others, reaching one's maximum potential.
Planning
The planning stage is where goals and outcomes are formulated that directly impact patient
care based on EDP guidelines. These patient-specific goals and the attainment of such
assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal
setting. Care plans provide a course of direction for personalized care tailored to an
individual's unique needs. Overall condition and comorbid conditions play a role in the
construction of a care plan. Care plans enhance communication, documentation,
reimbursement, and continuity of care across the healthcare continuum.
Goals should be:
Specific
Measurable or Meaningful
Attainable or Action-Oriented
Realistic or Results-Oriented
Timely or Time-Oriented
3-As you begin the assessment process, Mr. R stops you and says, "I don't know why you need
to do an assessment; I am just here to get my medicines adjusted."How would you respond to
Mr. S? Just listen to the patient what is his concern and go through an assessment before
adjusting drugs, keep good report, check vitals, mental status, and other risk factors.
What is the purpose of a psychiatric mental health nursing assessment? To establish rapport,
review physical and mental status; assess risk factors, formulate care plan.
CHAPTER 8:
1- Explain the three phases of the nurse-patient relationship?
Three Phases of Nurse-Client Relationship:
Orientation Stage
Establishing therapeutic environment.
The roles, goals, rules and limitations of the relationship are defined, nurse gains
trust of the client, and the mode of communication are acceptable for both nurse and
patient is set.
o Acceptance is the foundation of all therapeutic relationship
o Acceptance of others requires acceptance of self first.
Rapport is built by demonstrating acceptance and non-judgmental attitude.
, Acceptance of patient means encouraging the patient verbally and non-verbally to
express both positive and negative feelings even if these are divergent from
accepted norms and general viewpoint.
o The nurse can encourage the client to share his/her feelings by making the
client understand that no feeling is wrong.
Trust of patient is gained by being consistent.
Assessment of the client is made by obtaining data from primary and secondary
sources.
The patient set the pace of the relationship.
During this phase, the problems are not yet been resolved but the client's feelings
especially anxiety is reduced, by using palliative measures, to enable the client to
relax enough to talk about his distressing feelings and thoughts.
This stage progresses well when the nurses show empathy provide support to client
and temporary structure until the client can control his own feelings and behavior.
o Reality testing - is accepting the patient's perceptions, feelings and thoughts
as neither right nor wrong, but at the same time offering other options or
points of view to the client in a non-argumentative manner for the purpose of
helping the client arrive at more realistic conclusions.
o To provide structure is to intervene when the client loses control of his own
feelings and behaviors by medications, offering self, restrain, seclusion and
by assisting client to observe a consistent daily schedule.
Working/ Exploration/ Identification Stage - at this point, the client's problems are
identified and solutions are explored, applied and evaluated.
The focus of the assessment and of the relationship is the client's behavior and the
focus of the interaction is the client's feelings.
The nurse should realize that the client's feelings of security are developed by being
consistent at all times.
Perception of reality, coping mechanisms and support systems are identified.
The nurse assists the patient to develop coping skills, positive self concept and
independence in order to change the behavior of the client to one that is adaptive
and appropriate.
o The nurse uses the techniques of communication and assumes different
roles to help the client.
Termination/ Resolution stage
the nurse terminates the relationship when the mutually agreed goals are met, the
patient is discharged or transferred or the rotation is finished. The focus of this stage
is the growth that has occurred in the client and the nurse helps the patient to
become independent and responsible in making his own decisions. The relationship
and the growth or change that has occurred in both the nurse and the patient is
summarized.
Client may become anxious and react with increased dependence, hostility and
withdrawal, these are normal reactions and are signs of separation anxiety, these
feelings and behavior should be discussed with the client.
