Communication
Types of Communication
Intrapersonal: Communication within oneself, such as reflection or inner thoughts. Interpersonal: Direct communication between two or more people; key in nurse-patient relationships and teamwork.
Interprofessional: Communication between different healthcare team members; clear, structured communication ensures patient safety. Therapeutic: Purposeful, patient-centered communication that promotes healing using techniques like active listening and reflection.
Nurse-Client Relationship Orientation Phase - what happens?
TUG TEST INSTRUCTIONS
Have the patient sit in a chair. Ask them to stand up, walk 10 feet (3 meters), turn around, walk back, and sit down. Normal: Completes in <12 seconds.
>12 seconds: May indicate fall risk or mobility issues.
Types of Assessments
Initial: Comprehensive assessment performed on admission or entry. Problem-focused: Assessment focused on a specific problem or complaint. Ongoing: Continuous assessment performed at regular intervals. Emergency: Rapid assessment conducted in critical or life-threatening situations. Time-lapsed: Assessment performed after a longer period to compare changes over time.
BP should be taken after client rests for at least _______ minutes and has not smoked or ingested caffeine for at least _______ minutes. Because of the variations that occur during a typical day, readings on ______ or more occasions should be averaged before diagnosing high blood pressure.
5 minutes; 30 minutes; 2 or more
This emotional factor can raise heart rate even in the absence of physical exertion.
What is stress or anxiety? ALSO:
•Age: Decreases with age; •Gender: Lower in males after puberty; •Fever: Increases due to higher metabolism and vasodilation; •Hypovolemia: Blood loss → ↑ pulse (SNS response); •Hypoxia/Hypoxemia: Low O₂ → ↑ pulse; •Stress: Fear, anxiety, pain → ↑ pulse
What does each letter stand for? SBAR
SBAR communication requires the sharing of clear information focused on the four topical areas: Situation: What is happening right now? Background: What led to the current situation? Assessment: What is the identified problem, concern, or need? Recommendation: What actions or interventions should be initiated to alleviate the problem
Nurse-Client Relationship Working Phase - what happens?
HOB Elevation for Semi-Fowler’s; Fowler’s; High Fowler’s
Semi-Fowler’s (15-45) Fowler’s (45-60) High Fowler’s (60-90)
Inspection: Definition and Purpose
Inspection involves using the senses of vision, smell (olfaction), and hearing to observe and detect any expected or unexpected findings. Inspect for size, shape, color, symmetry (comparing both sides of the body), and position. The first step of a physical exam and provides immediate clues about the patient’s health status.
Dysrhythmias can be benign or indicative of serious conditions. When an irregular pulse is noted, the ____________ pulse should be assessed for ________.
Dysrhythmias can be benign or indicative of serious conditions. When an irregular pulse is noted, the apical pulse should be assessed for one full minute.
This condition may cause rapid, shallow respirations due to stimulation of pain receptors.
What is pain? Factors that Affect Resp -
•Age: Rate decreases with age; stabilizes in late adolescence; •Exercise: Increases rate and depth; •Cardiovascular disease, anemia → ↑ rate;•Respiratory diseases → labored, shallow, rapid breathing; •Smoking → airway changes, ↑ rate; •Pain: Acute pain → ↑ rate, ↓ depth; •Emotions: Fear, anxiety → ↑ rate, ↓ depth
Open-ended questions are best used when?
Nurse-Client Relationship Termination Phase - what happens?
Active, Passive, and Active Assist Descriptions
Active: The patient has full independent movement of all joints; Passive: The caregiver moves the patient’s joints through a full motion. Active Assist: Patient moves the joint as much as possible, with assistance to complete the movement.
Palpation: Definition and Purpose
Palpation is the technique of using the hands to feel the body for abnormalities during a physical exam; Assesses texture, temperature, moisture, size, and shape of organs and tissues.
The dorsal (back) surface is the most sensitive to temperature. The palmar (front) surface and base of the fingers are sensitive to vibration.
Homeostasis Effects on Vital Signs: ↓ Oxygen levels? ↑ Body temperature? ↓ Blood pressure; Pain or stress
↓ Oxygen levels (SpO₂) → ↑ Heart rate (HR) to deliver more oxygen to tissues.
↑ Body temperature → ↑ Respiratory rate (RR) to help cool the body.
↓ Blood pressure (BP) → ↑ Heart rate to maintain adequate circulation.
Pain or stress → ↑ HR, BP, and RR due to sympathetic nervous system activation.
This age-related change makes older adults more vulnerable to hypothermia.
What is decreased metabolism or reduced subcutaneous fat?
Closed-ended questions are best used when?
Defense Mechanisms - Denial; Displacement; Regression
Denial: Denying an event or item’s existence. Displacement: Redirecting emotions to a safer target. Regression: Returning to behaviors of the past
Best Lifting Techniques
Wide base of support; Keeping the object close; Bend at knees: Avoid bending at the waist to prevent back strain; use leg muscles for lifting. Engage core; Smooth movements; Avoid twisting your spine; pivot your feet instead. Assistive devices: Use gait belts, lifts, or other equipment when appropriate, and always ask for help when needed.
Percussion: Definition and Purpose
Percussion involves tapping body parts with fingers, fists, or small instruments to vibrate underlying tissues to determine the size and location; detect tenderness or abnormalities, and to check for the presence or absence of fluid or air in the tissues.
Key points for the RN who delegates Vital Signs to a UAP.
•The RN assesses the patient and determines if the task is appropriate to delegate. •Delegated tasks must match the knowledge, skill, and scope of practice of the person receiving the task. •The RN provides clear instructions, ensures proper supervision, and evaluates the results. •The RN remains accountable for the patient's care and the outcomes of delegated tasks.
This environmental factor may falsely elevate oral temperature readings.
What is the recent intake of hot food or fluids? Other Factors that Affect Temp: Age → Newborns & older adults ↓ thermoregulation; Environment → Hot/cold surroundings alter temperature; Exercise/Activity → ↑ metabolism → ↑ temperature; Stress/Emotions → Sympathetic response → slight ↑ temperature; Illness/Infection → Inflammation → fever; Time of Day → AM ↓ | PM ↑ (circadian rhythm); Hydration/Metabolism → Poor hydration or altered metabolism → impaired regulation; Smoking → Vasoconstriction → ↓ skin & mucous membrane temperature
Hearing Impaired Considerations
Defense Mechanisms: Avoidance, Projection; Repression
Avoidance: Not facing a situation, person, or item by minimizing encounters. Projection: Transferring certain qualities to another person; Repression: Subconsciously removing negative experience(s) from consciousness
Gait Belt: Should be applied snugly around the patient’s _________, leaving enough room to fit ____ fingers between the belt and the patient. When assisting a patient with a weaker side during ambulation, the nurse should stand on the patient’s __________ side for safety and support.
Auscultation: Definition and Purpose
Auscultation is the process of listening to sounds the body produces to identify unexpected findings. Evaluate sounds for amplitude or intensity (loud or soft), pitch or frequency (high or low), duration (time the sound lasts), and quality (what it sounds like).
Vital Signs: Changes across the Lifespan. Heart Rate, BP, Resp Rate; Temp.
Heart Rate: Decreases with age; Blood Pressure: Increases with age; Respiratory Rate: Decreases with age; Temperature: Slightly lower in older adults
This body position change may cause a drop in blood pressure when standing.
What is orthostatic hypotension?
•Sudden drop with position changes:
•↓ 20 mm Hg systolic
•↓ 10 mm Hg diastolic
Visually impaired considerations
Identify yourself when entering the room. Explain actions before touching or performing procedures. Use verbal descriptions instead of gestures or visual cues. Provide materials in accessible formats such as large print, Braille, or audio.
Examples of Non-Therapeutic Communication: False Reassurance; Asking Why?; Offering Value Judgments. Offering Sympathy.
False Reassureance: “Don’t worry, everything will be fine.” Why? “Why didn’t you take your medicine?” Value Judgments: “You’re such a good patient when you follow instructions.” Offering Sympathy: “I feel so sorry for you; this must be awful.
Recommended Adult Exercise
Aerobic → 150 min moderate or 75 min vigorous/week
Strength → 2 days/week (all major muscle groups)
Flexibility/Balance → 2–3 days/week (especially older adults)
Exam Sequence
For most body systems, follow the sequence of first inspecting, then palpating, followed by percussion, and finally auscultation. The exception is the abdomen; inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds.
ATI Chapter 26 page 131
Define Dyspnea and Orthopnea. What position can help the client?
Dypnea: Labored, difficult breathing, often shallow and rapid. Orthopnea: Difficulty breathing when lying flat that is relieved by sitting or standing.
Tripod or Orthopneic (or-THOP-nee-ik)
Mobility: Lordosis, Kyphosis, and Scolosis
Lordosis → Exaggerated inward curve of the lumbar spine Often called “swayback”
Kyphosis → Exaggerated outward curve of the thoracic spine; Hunched or rounded upper back
Scoliosis → Lateral (sideways) curvature of the spine; Spine curves in an “S” or “C” shape
SOLER Technique for Active Listening
S – Sit Facing the Patient: Sit down to show you’re present and engaged. O – Open Posture: Keep arms and legs uncrossed to show openness and interest. L – Lean Toward the Speaker: Slightly lean in to show attentiveness without invading space. E – Eye Contact: Maintain natural, respectful eye contact to show connection and focus. R – Relax: Stay calm and relaxed to help the patient feel comfortable and safe.
If a patient’s verbal and nonverbal communication are inconsistent, which form of communication best reflects the patient’s true feelings?
Recommended Child (6-17) Exercise
Aerobic → at least 1 hr/day moderate–vigorous (run, bike, swim, active play); Strength → ≥3 days/week (climb, push-ups, playground); Bone-Strengthening → ≥3 days/week (jumping, running)
A nurse notes bluish discoloration of the nail beds and lips in a client with respiratory distress. This finding reflects inadequate oxygen delivery at the tissue level.
What is cyanosis?
2+
•0: Absent, unable to palpate; •1+: Diminished, weaker than expected; •2+: Brisk, expected (normal); •3+: Increased, strong; •4+: Full volume, bounding
Assessment: Light Palpation versus Deep
•Light → Surface characteristics; 1 cm
•Deep → Deeper organs/structures; 4 cm