Nursing Process
A nurse interviews a patient to gather information
What is assessment?
Hands-on, face-to-face interaction between a healthcare professional and a patient to provide medical services, including diagnosis, treatment, and prevention of illnesses
What is direct care?
Acknowledging and accepting a person's thoughts, feelings, and experiences as valid and understandable, even if you don't personally agree with them
What is validating?
A formal document that records the details of an event, often an accident or injury, and primarily used for research and quality improvement purposes
What is an incident report?
Indirectly expressing anger or resentment through passive behaviors; sabotaging or undermining others.
What is passive aggressive communication?
A nurse consults with the interdisciplinary team to define and prioritize patient needs.
What is diagnosis?
The development of nursing diagnoses, and completion or coordination of the admission assessment
What are is included in the RN only role?
This encourages detailed responses and deeper exploration of a patient's thoughts and feelings. It promotes a flow of communication that can reveal valuable insights and foster a stronger therapeutic relationship.
A crucial principle of electronic charting in nursing that ensures data accuracy and patient safety
What is documentating immediately?
Avoiding expressing one's feelings or needs; allowing others to take advantage of them.
What is passive communication?
A nurse collaborates with a patient to develop a plan of care
What is planning?
A communication framework in healthcare that stands for Acknowledge, Introduce, Duration, Explanation, and Thank You
What is AIDET?
When a healthcare professional offers comfort or assurance to a patient that is not based on facts or reality
What is false reassurance?
Patient problems (Data)
nursing interventions (Actions)
patient outcomes (Responses)
What is a DAR note?
Model that describes communication as a dynamic, ongoing process where individuals simultaneously send and receive messages, influencing each other in real-time, is reciprocal and interactive
What is the transactional model of communication?
A nurse uses teach-back to assure patient understands how to take an antihypertensive medication properly.
What is implementation?
Model that emphasizes the importance of a trusting, collaborative relationship between the nurse and patient, where mutual respect and shared decision-making support holistic and individualized care, helps prepare the nurse to engage in therapeutic communication.
What is the SURETY model?
A component of therapeutic that involves understanding and sharing the client's feelings, active listening, reflecting on the client's emotions, and validating their experiences.
What is empathy?
Document of client data and determine reimbursement in long term care.
What is the Resident Assessment Instrument (RAI) ?
The ability to assess patient information, interpret its significance, and make informed decisions to provide safe and effective care
What is clinical judgment?
A nurse interviews a patient to assess their progress
What is evaluation?
The LPN must collaborate with the RN to care for patients during which two steps of the nursing process?
What are assessment and diagnosis?
Paying attention to the speaker, showing that you're listening through nonverbal cues and verbal affirmations.
What is active listening?
This application supports the work of nurses in the delivery and documentation of care by providing easy organized access to the documentation record, and assist in care delivery such as care planning.
What is the Nursing Clinical Information Systems (NCIS)?
Taking extra time, paying attention to age-related considerations and normal/abnormal assessments, listening to the client verbalize their story, using open-ended questions.
What are modifications when assessing an adult client?