Fundamental Concepts and Skills For Nursing - (Unit III Communication in Nursing)

Unit III Communication in Nursing
chapter
Documentation of Nursing Care 7

http://evolve.elsevier.com/deWit/fundamental
Objectives
Upon completing this chapter, you should be able to:
Theory Clinical Practice
1. Identify three purposes of documentation. 1. Correctly make entries on a daily care flow sheet.
2. Correlate the nursing process with the process of charting. 2. Use a systematic way of charting to ensure that all
3. Discuss maintaining confidentiality and privacy of paper or pertinent information has been included.
electronic medical records. 3. Document the characterization of signs or symptoms in a
4. Compare and contrast the six main methods of written sample charting situation.
documentation. 4. Apply the general charting guidelines in the clinical setting.
5. List the legal guidelines for recording on medical records. 5. Navigate electronic medical records and document care
6. Relate the approved way to correct errors in medical correctly.
records.
Key Terms
case management system charting (p. 83) medical record (chart) (p. 81)
charting (p. 83) PIE charting (p. 86)
charting by exception (p. 83) problem-oriented medical record (POMR) charting
computer-assisted charting (p. 83) (p. 83)
computerized provider order entry (CPOE) (p. 88) protocols (PRŌ-tō-kŏlz, p. 87)
electronic health record (EHR) (p. 87) source-oriented (narrative) charting (p. 83)
focus charting (p. 83)
sets the standards for documentation. Common types of

PURPOSES OF DOCUMENTATION
forms in patient charts are listed in Table 7-1.
Copyright © 2013. Elsevier Health Sciences. All rights reserved.
Documentation provides a written record of the history, Insurance companies and Medicare rely on docu-
treatment, care, and response of the patient while under mentation to determine actual length of stay, proce-
medical and nursing care. It justifies claims for reim- dures performed, and diagnoses established and to
bursement, may be used as evidence of care in a court of calculate charges due for reimbursement. Each piece of
law, shows the use of the nursing process, and provides equipment in service must be documented. Charts
data for quality assurance studies. Each person who pro- must display data that support the medical and nurs-
vides care for the patient adds written documentation to ing diagnoses. Evaluation data indicating that the
the medical record (chart). The medical record contains treatment was successful or unsuccessful must be pres-
all orders, tests, treatments, and care that occurred while ent to justify the duration of the hospital stay. Docu-
the person was under the care of the health care provider. mentation of this type is also necessary for accreditation
The chart is a communication tool for the professionals of the health care agency. Charts are also used for
involved in patient care. Health team members use doc- research data collection. For example, statistics may be
umentation to communicate what has been done, how compiled for the number of cases of pneumonia
the patient responded, and the current plan for care. treated, the average age of the patients, and treatment
Many different forms are used for documentation, and results to see which treatments are most effective.
the most common forms are shown in the chapters spe- The medical record is a legal record and can be
cific to their content; for example, an intravenous (IV) used as evidence of events that occurred or treatment
flow sheet is shown in Chapter 36. The Joint Commission that was given. When documentation is thorough, the
deWit, Susan C., and Patricia A. Williams. Fundamental Concepts and Skills for Nursing, Elsevier Health Sciences, 2013. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/qut/detail.action?docID=2074485.
81
Created from qut on 2018-02-13 01:53:13.
82 UNIT III Communication in Nursing
Table 7-1 Forms Used for Hospital Documentation

FORM TYPE OF INFORMATION
General Forms
Face sheet Patient data, including the patient’s name, address, phone number, next of kin, hospital identifi-
cation number, religious preference, place of employment, insurance company, occupation,
name of admitting physician, and admitting diagnosis
Physician’s orders The physician’s directives for patient care
Graphic sheet Record of serial measurements and observations, such as temperature, pulse, respiration, blood
pressure, weight
Nursing care plan Care plan for the patient, including nursing diagnoses, goals and expected outcomes, and
nursing interventions
Nurse’s notes Written report of the nursing process (i.e., assessment, nursing diagnosis, planning, implementa-
tion, and evaluation); record of interventions implemented and the patient’s response to them
Care flow sheet Form on which check marks or short entries are made to indicate dietary intake, type of bath,
wound dressing changes, oxygen in use, physician visits, equipment in use, level of activity,
and so forth
Medication administration Documentation of all medications ordered, doses given, and doses not taken by the patient
record (MAR)
History and physical Physician’s record of the patient’s medical history and findings of the current physical examination
examination forms
Nurse’s admission history Nurse’s current history, including usual habits, medications usually taken, and physical assess-
and assessment ment findings at admission
Progress sheet Physician’s notes regarding the patient’s progress
Laboratory reports Results of laboratory tests
Radiology reports Results of x-ray examinations
Admission forms Information on patient identification, conditions for admission, and consent for general medical
and nursing care
Intake and output (I&O) Serial record of 24-hr intake and output
record
Miscellaneous Forms
Ancillary staff sheets Records of treatments by physical therapists, occupational therapists, respiratory therapists, and
so forth
Consultation sheet Record of another physician called in to consult by the attending physician
Diabetic flow sheet Record of blood glucose determinations and amounts of insulin administered
Discharge form Information about instructions given regarding wound care, medications, rest, activity restrictions,
needed exercises, diet, and signs and symptoms to report to the physician; also includes when
to next see the physician
Discharge planning sheet Records by social services, home health agencies, case managers, and clinical nurse specialists
regarding the discharge plans and patient’s needs
Fall risk assessment Information regarding the patient’s potential fall risk; particularly used for frail, elderly, or patients
with neuromuscular impairments
Frequent observations Used when frequent measurements of vital signs or neurologic assessments are needed (e.g.,
sheet after surgery or after head trauma)
Intravenous (IV) flow sheet Record of IV fluids and additives infused, type of IV catheter in use, date tubing was changed,
date dressing was applied
Pain assessment Record of pain level, when assessed, measures to reduce it, effectiveness of treatment
Preoperative checklist List used to verify that the patient is ready to go to surgery
Skin risk assessment Data from thorough skin assessment on admission; evaluation of risk factors for skin breakdown;
diagrams showing areas of redness, breaks in the skin, or pressure ulcers
Surgical or treatment Patient authorization for surgery or treatment
consent form
Time-out form Patient verification, site mark verification, and time out performed before surgical procedure
Transfer form Information pertinent for the transfer of the patient to another unit or facility
Documentation of Nursing Care CHAPTER 7 83
record provides a way to show that standards of care those involved in research or teaching, should have
have been met. access to the chart. Protecting the patient’s privacy is of
Documentation, also called charting, is used to track prime importance. Do not discuss patient information
the application of the nursing process. The nurse writes with others not directly involved in the patient’s care.
down observations made about the patient, notes the The chart is the property of the health facility or
care and treatment that was delivered, and adds the agency, not of the patient or physician. Patients do have
patient’s response. Documentation shows progress a right to information contained in the chart under cer-
toward the expected outcomes listed on the nursing tain circumstances (see Chapter 3). Keeping the patient
care plan. and the family informed in a clear and timely manner
Documentation is useful for supervisory purposes usually satisfies their need for information. After the
to evaluate staff performance. Charting is audited as patient has been discharged, the chart is sent to the
part of the health care agency’s quality improvement medical records or health information department for
program. Evidence that care adheres to accepted stan- safekeeping. It can be retrieved if the patient is admit-
dards should be present in the nurse’s notes. The ted to service again within a 10-year span. Electronic
results of chart audits tell nurse managers where records may be kept for longer periods, ranging from
improvement may be needed. 10 years to indefinitely, depending on the state where
the patient resides (Dixon and Shepard, 2008).
DOCUMENTATION AND THE NURSING PROCESS
Think Critically
The written nursing care plan or interdisciplinary care
plan provides the framework for nursing documenta- What would you say to your neighbor, who sees you working
tion. Charting is organized by nursing diagnosis or on the unit on which her sister’s husband is a patient, if she
problem. An initial assessment is charted for each shift. asks you to check and see what her brother-in-law’s physician
has charted about his condition?
Standard areas of assessment are usually noted on
flow sheets, and a written note is added if an abnor-

mality exists. Nursing diagnoses or problems are
METHODS OF DOCUMENTATION (CHARTING)
entered on the care plan, which is created soon after
the admission assessment is complete. The plan is Different methods of charting are used in various health
reviewed and updated every 24 hours. Implementa- care agencies. The six main methods of charting are (1)
tion of each intervention is documented on a flow sheet source-oriented (narrative) charting, which is organized
or within the nursing notes. The specifics of what was by “source” or author of the charting entry; (2) problem-
done and how, plus the patient response, are charted. oriented medical record (POMR) charting, which focuses
Evaluation statements are placed in the nurse’s notes on the problems the patient experiences as a result of
and indicate progress toward the stated expected out- being ill; (3) focus charting, which centers on the patient
comes and goals. Evaluation data must be documented from a positive perspective; (4) charting by exception,
showing that expected outcomes have been achieved which focuses on deviations from predefined norms,
before a nursing diagnosis is marked “resolved” or using preset protocols and standards of care; (5)
deleted from the care plan. When expected outcomes omputer-assisted charting, where data are input to the
c
are not being met, the care plan is altered. computer; and (6) case management system charting,
which tracks variances from the clinical pathway.

Whatever method of documentation is used, you
Think Critically
are required to chart the patient’s progress periodically
If evaluation data are not showing progress toward expected during the shift or at the time of a home health visit.
outcomes, what part of the nursing care plan needs to be The chart entries are either in your notes or on flow
altered? Where in the chart would this be done? sheets (Figure 7-1). Flow sheets track routine assess-

ments, treatments, and frequently given care. The spe-

cific time frame required for charting is found in the
THE MEDICAL RECORD agency’s policy and procedure manual. Some agencies
The medical record, or chart, contains data on a patient’s require one note per patient contact; others require
stay in the health facility or while under the care of a charting every 1 to 3 hours during the shift.
health care provider. Each type of facility has a particular
set of forms used to record information about the patient. SOURCE-ORIENTED OR NARRATIVE CHARTING
As a legal record, the chart’s contents are confiden- These records are organized according to the source
tial; this means you can only give out information with of information. There are separate forms for physi-
the patient’s written consent, since the chart contains cians (focusing on medical problems), nurses (focus-
personal information regarding the patient. Only ing on nursing diagnoses), dietitians, and other health
health professionals caring directly for the patient, or care professionals to document their assessment
FLOWSHEET 10/10 10/11 Doe, John B.

ADLs—cont’d 11-7 7-3 3-11 Neverland Hospital
Ambulate done From 10/10/13 to 10/11/13
RN Room 645-1 ADM 10/09/13
FR 10:00 Age 63Y Sex M
done MD Sawbucks, Jackson
self ID 4620958 MR 102756
FR 14:00
Activity response tolerated well tolerated well

FR 08:00 FR 16:00
tolerated well tolerated well
FR 10:00 RJK 20:00
tolerated well tolerated well
FR 14:00 RJK 22:00
Feeding self
assist
FR 08:00
self
assist
FRI 12:00
Diet regular
FR 08:00
regular
FR 12:00
Ate % 80%
FR 08:00
80%
FR 12:00
Hygiene assist bath

perineal care
skin care
back rub
linen change
FR 10:00
Standard prec yes yes

FR 08:00 RJK 20:00
yes yes
FR 10:00 RJK 22:00
SKIN 11-7 7-3 3-11
Skin assmnt WNL WNL WNL
RJK 00:00 FR 08:00 RJK 20:00
Braden sc 21 21 21
RJK 00:00 FR 08:00 RJK 22:00
INC/WDS UPPER 11-7 7-3 3-11
L shoulder
Wound type incision incision incision
RJK 00:00 FR 08:00 RJK 20:00
Wound appearance
dry dry dry
clean clean clean
RJK 00:00 FR 08:00 RJK 20:00

L shoulder
Wound dressing
dry intact dry intact dry intact
checked checked FR 08:00 checked
RJK 00:00 RJK 20:00
IV LINES 11-7 7-3 3-11

R subclavian
Line type triple triple triple
RJK 00:00 FR 08:00 RJK 20:00
Rutken, Frances (FR) RN Kahn, Roland J. (RJK) LPN
FIGURE 7-1 Computer activity flow sheet.
findings and plan the patient’s care. Narrative notes The content is similar to a set of dated and timed jour-
are phrases and sentences written without any stan- nal entries (Figure 7-2).
dardized structure, content, or form. Narrative chart- Advantages of the source-oriented (narrative)
ing used in source-oriented records requires method are as follows:
documentation of patient care in chronologic order. • It gives information on the patient’s condition
Assessments usually follow a body systems format. and care in chronologic order.
Date Time Problem Nurse’s Notes

6/25/13 2015 #1 States has “sharp throbbing” pain at a 7 on a 1-10 pain scale.
Started at 2000 when amb down hall. T 99, P 88, R 24, BP
146/82. Unrelieved by change in position or rest.----R. Hill, LVN
2020 Meperidine 75 mg IM RUOQ. R. Hill, LVN
2045 Resting quietly in bed. P 86, R 20, BP 146/78. States pain “has
decreased considerably.” R. Hill, LVN
FIGURE 7-2 Example of source-oriented (narrative) charting.
• It indicates the patient’s baseline condition for Major Components of the Problem-Oriented
each shift. Table 7-2
Medical Record
• It includes aspects of all steps of the nursing
AREA CONTENTS
process.
Database Initial assessment, general health history,
Disadvantages of the source-oriented method are as
findings of the physical examination,
follows:
results of diagnostic and laboratory
• It encourages documentation of both normal and tests, psychosocial information,
abnormal findings, making it difficult to separate nursing assessment, patient’s
pertinent from irrelevant information. response to the illness or problem.
• It requires extensive charting time by the staff. Problem list A list of problems derived from the
• It discourages physicians and other health team information in the database. The list is
members from reading all parts of the chart continually updated with resolved
because of the lengthy descriptive entries in it. problems deleted and new problems
added. Problems are listed in the
PROBLEM-ORIENTED MEDICAL RECORD chronologic order in which they were
(POMR) CHARTING identified, not by priority. Both actual
POMR charting focuses on patient status, emphasizing and potential problems are listed.
the problem-solving approach to patient care and pro- Plan A three-part plan of care is devised
viding a method for communicating what, when, and based on the identified problems. For
how things are to be done to meet the patient’s needs. each problem there is a plan for
The POMR contains five basic parts: the database, the diagnostic studies, a therapeutic plan,
problem list, the plan, the progress notes (in which all and a teaching plan. The physician
orders therapies for medical problems,
members of the health care team document), and the
and the nurse orders care for nursing
discharge summary (Table 7-2). The precise form these problems.
records take varies greatly between agencies, but the
Progress Contain the assessments, plans, and
essentials of charting are the same.
notes orders of the physicians, nurses, and
As this documentation method evolved, the original other therapists involved in the
SOAP format for progress notes (for Subjective infor- patient’s care. Notes are organized by
mation, Objective data, Assessment data, and Plan) problem number from the problem list,
was modified to SOAPIE and SOAPIER. The addi- and each problem is addressed in the
tional letters stand for Implementation, Evaluation, SOAP format:
and Revision. It is not necessary to use each compo- S: Subjective data that include
nent of the SOAPIER format each time you make an symptoms and patient’s description
entry. If there are no subjective data, the S can be omit- of the problem
ted or labeled “none.” If there is no revision, the R can O: Objective data based on health
be left out (Figure 7-3). care team’s observations, physical
examination, and diagnostic tests
Advantages of the POMR method of documentation
A: Assessment or analysis of the
are as follows: meaning of the data obtained
• It provides documentation of comprehensive P: Plan to resolve the problem
care by focusing on patients and their problems. It is not essential to write a progress note
• It promotes the problem-solving approach to care. on each problem every day.
• It improves continuity of care and communica- Discharge A summary of the problems the patient
tion by keeping data relevant to a problem all in summary had, how they were resolved, and the
one place so that it is more available to all who plan for care after discharge.
are providing care.
• It allows easy auditing of patient records in evalu-
ating staff performance or quality of patient care.

7/18/13 0800 #2 Pain, Abd S. States having RUQ pain radiating to right shoulder. Is “like
a knife is poking me.” States is a 6 on a scale of 1-10. “It
started after I ate the bacon.” States feels nauseous, but no
vomiting.-------------------------------------------------------------
O. Pale, diaphoretic and shaky. Splinting abd c hands.
T 100° F, P 112, R 22, BP 134/88.
A. Abd pain.
P. Institute NPO status; medicate when IM order received.
Notify physician.-------------------------------------J. Sims, RN

6/25/13 1620 #1 Hypertension S. States feeling “warm and restless.”-----------------------------
O. Face flushed; skin hot to touch. T 103° F, P 120, R 26,
BP 160/90.---------------------------------------------------------------
A. Hyperthermia r/t wound infection.
P. Medicate for ↑ temp.-----------------------------------------------
1625 I. Acetaminophen 500 mg PO c full glass of H2O. Gown
changed. Heat turned down, blanket removed.-----------------
1700 E. T 101.6°F, P 95, R 24; temp falling. States is feeling better.
Skin cooler to touch.----------------------------M. Bailey, LPN
B
FIGURE 7-3 A, Example of problem-oriented medical record (POMR) charting. B, Example of SOAPIE (Subjective, Objective, Assessment, Plan,
Implementation, Evaluation) charting.

7/18/13 1420 Pain r/t ROM P. Reinstruct in use of PCA and measures for distraction.
exercises of rt I. Instructions for use of PCA given; encouraged to watch
knee by CPM TV movie for distraction. Knee position on CPM machine
machine OK; machine functioning at ordered settings. Repositioned
upper body for comfort.
E. Using PCA as needed; pain decreased. States is tolerable at
3 on a scale of 1-10. Watching movie.--------C. Harris, LPN
FIGURE 7-4 Example of PIE (Problem, Intervention, Evaluation) charting.
• It requires continual evaluation and revision of the P of the PIE format. Nursing diagnoses are kept on
the care plan. a problem list (P), and each charting entry is marked
• It reinforces application of the nursing process. with the problem number and title. With this method,
Disadvantages of the POMR method of documenta- the daily assessment information is placed on special
tion are as follows: flow sheets, and duplication of the information is
• It results in loss of chronologic charting. avoided. Interventions performed are documented
• It is more difficult to track trends in patient status. under I. The outcomes of the interventions are evalu-
• It fragments data because of the increased num- ated and documented under E (Figure 7-4). When
ber of flow sheets required. assessment data are abnormal, an A is added (APIE).
PIE Charting FOCUS CHARTING

Another offshoot of this method is PIE charting, which Focus charting is similar to the POMR system but it
stands for Problem identification, Interventions, and substitutes focus for the problem, eliminating the neg-
Evaluation. This type of charting follows the nursing ative connotation attached to “problem.” Focus chart-
process and uses nursing diagnoses while placing the ing is directed at a nursing diagnosis (e.g., pain), a
plan of care within the nurses’ progress notes. It differs patient problem (pressure ulcer), a concern (decreased
from SOAP notes because it does not use a traditional food intake), a sign (fever), a symptom (anxiety), or an
nursing care plan or require narrative charting of the event (return from surgery). The note has three compo-
assessment data as long as they are normal. The prob- nents: Data, Action, and Response (DAR) or Data,
lems, teaching, and discharge needs are listed under Action, and Evaluation (DAE) (Figure 7-5). The data
Date Time Problem Patient Progress

7/01/13 1300 Impaired skin D. Slight serous drainage on dressing; wound 1x2 cm c left red
integrity right border; no odor; states hurts slightly.----------------------------
ankle A. Cleansed c sterile saline. DuoDerm thin applied.
R. Wound clean; minimal drainage present.-----T. Harper, RN
FIGURE 7-5 Example of focus charting.
component contains subjective and objective informa- • It eliminates duplication of charting.
tion that describes or supports the focus of the note. • It lends itself to computerized charting systems.
The action component includes interventions per- Disadvantages of charting by exception are as
formed or to be implemented. The response compo- follows:
nent describes the outcomes of the interventions and • It requires development of detailed protocols and
whether the goal has been met. standards.
The advantages of focus charting are as follows: • It requires retraining staff to use unfamiliar meth-
• It is compatible with the use of the nursing process. ods of record keeping and recording.
• It shortens charting time by using many flow • Nurses become so used to not charting that
sheets and checklists. important data are sometimes omitted.
• The focus is not limited to patient problems or
nursing diagnoses. COMPUTER-ASSISTED CHARTING
The disadvantages of focus charting are as follows: An electronic health record (EHR) is a computerized
• If the database is not complete, patient problems comprehensive record of a patient’s history and care
may be missed. across all facilities and admissions. This type of record
• It does not adhere to charting with the focus on is a goal for the entire medical industry by 2014, man-
nursing diagnoses and expected outcomes. dated by the Stimulus Law that President Obama
signed in 2009. The QSEN project (see Chapter 3) iden-
CHARTING BY EXCEPTION tifies informatics as one of the major areas where preli-
Charting by exception was developed in the early 1980s censure knowledge, skills, and attitudes (KSAs) are
by a group of nurses in Wisconsin. The goal was to important for nursing students to acquire.
decrease the lengthy narrative entries of traditional Security and confidentiality of records are major
charting systems and reduce repetition of data. Charting concerns. Within a hospital system, computer records
by exception is based on the assumption that all stan- are protected by passwords and a firewall. With the
dards of practice are carried out and met with a normal addition of wireless technology, the security issues
or expected response unless otherwise documented. have increased. Each user who has access to a patient
Agency-wide and unit-specific protocols (standard pro- record must have a secure password, which must be
cedures) and standards of nursing care are the heart of changed regularly to maintain security. Encryption
the system. The standards and protocols are integrated and authentication software is used when reports are
into flow sheets and forms, and the nurse needs only to transmitted outside of the health care facility campus.
document abnormal findings or responses correlated See Box 7-1 on p. 90 for tips on computer charting.
with the nursing diagnoses listed on the nursing care
plan (Figure 7-6). A longhand note is written only when
the standardized statement on the form is not met
(Figure 7-7). Otherwise only a signature is necessary.
Charting by exception is the direct opposite of the Legal & Ethical Considerations
adage, “If it wasn’t charted, it wasn’t done.” Charting Confidentiality and Security with Computer Charting
by exception assumes that, unless documented to the You have a legal obligation to guard your password and to not
contrary, all standards and protocols were followed give it to anyone at any time for any reason. If you use printed
and all assessment values were within accepted limits. automated Kardex sheets while caring for patients, be sure to
This type of charting may present some problems with shred them at the end of the shift before leaving the unit.
legalities when a chart is called into court because only HIPAA requirements mandate that all patient information be
abnormalities are documented in written words. kept confidential.
The advantages of charting by exception are as Although your password gives you access to the records of
follows: patients on your unit, you will not be able to access patient
• It highlights abnormal data and patient trends. records on other units. Only administrative personnel can view
the record of any patient in the hospital.
• It decreases narrative charting time.
GUIDELINES FOR USE OF THE NURSING/PHYSICIAN ORDER FLOW SHEET

1. Indicate the Nursing Diagnosis that relates to the nursing order in the far left-hand column of the category boxes. If the order is a
physician order, indicate “D.O.” (“Doctor Order”) instead of the nursing diagnosis number.
2. Indicate the nursing or physician order. If the nursing order includes an assessment to be completed, use the following protocol:
a. NEUROLOGIC ASSESSMENT - will include orientation, pupil movement, sensation, quality of speech/swallowing, and memory.
b. CARDIOVASCULAR ASSESSMENT - will include apical pulse, neck veins, CRT, peripheral pulses, edema, and calf tenderness.
c. RESPIRATORY ASSESSMENT - will include respiratory characteristics, breath sounds, cough, sputum, color of nailbeds/mucous
membranes, and CRT.
d. GASTROINTESTINAL ASSESSMENT - will include abdominal appearance, bowel sounds, palpation, diet tolerance, and stools.
e. URINARY ASSESSMENT - will include voiding patterns, bladder distention, and urine characteristics.
f. INTEGUMENTARY ASSESSMENT - will include skin color, skin temperature, skin integrity, and condition of mucous membranes.
g. MUSCULOSKELETAL ASSESSMENT - will include joint swelling, tenderness, limitations in ROM, muscle strength, and condition
of surrounding tissue.
h. NEUROVASCULAR ASSESSMENT - will include color, temperature, movement, CRT, peripheral pulses, edema, and patient
description of sensation to affected extremity.
i. SURGICAL DRESSING/INCISIONAL ASSESSMENT - will include condition of surgical dressing and/or color, temperature,
tenderness of surrounding tissue, condition of sutures/staples/steri-strips, appearance of wound including color, any exudate
present, granulation tissue; approximation of wound edges, and presence of any drainage.
j. PAIN ASSESSMENT - will include patient description, location, duration, intensity on a scale of 1 to 10, radiation, precipitating
factors.
k. POST-MYELOGRAM COMPLICATION ASSESSMENT - will include headache, nausea, and vomiting.
l. MYELOGRAM SITE ASSESSMENT - will include presence of ecchymosis and drainage.
OR
Specify exactly which parts of assessment should be completed.

3. Top of sheet should be dated. Time should be indicated in the small box in upper right-hand corner of each category box.
4. Upon carrying out an order that has no significant findings, a “ ” in the appropriate category box is sufficient to indicate it was
done. If the order includes an assessment, the following parameters will be considered a negative assessment and constitute the
use of a “ ”.
a. NEUROLOGIC ASSESSMENT - Alert and oriented to person, place, and time. Behavior appropriate to situation. Pupils equal,
round and reactive to light. Active ROM of all extremities with symmetry of strength. No paresthesia. Verbalization clear and
understandable. Swallowing without coughing or choking on liquids and solids. Memory intact.
b. CARDIOVASCULAR ASSESSMENT - Regular apical pulse, S1 and S2 audible. Neck veins flat at 45 degrees. CRT <3 sec.
Peripheral pulses palpable. No edema. No calf tenderness.
c. RESPIRATORY ASSESSMENT - Respirations 10-20/min at rest. Respirations quiet and regular. Breath sounds vesicular
throughout both lung fields, bronchial over major airways, with no adventitious sounds. Sputum clear. Nailbeds and mucous
membranes pink. CRT <3 sec.
d. GASTROINTESTINAL ASSESSMENT - Abdomen soft. Bowel sounds active (5-34/min.) No pain with palpation. Tolerates
prescribed diet without nausea and vomiting. Having BMs within own normal pattern and consistency.
e. URINARY ASSESSMENT - Able to empty bladder without dysuria. Bladder not distended after voiding. Urine clear and yellow to
amber.
f. INTEGUMENTARY ASSESSMENT - Skin color within patient’s norm. Skin warm and intact. Mucous membranes moist.
g. MUSCULOSKELETAL ASSESSMENT - Absence of joint swelling and tenderness. Normal ROM of all joints. NO muscle
weakness. Surrounding tissues show no evidence of inflammation, nodules, nail changes, ulcerations, or rashes.
h. NEUROVASCULAR ASSESSMENT - Affected extremity is pink, warm and movable within patient’s average ROM. CRT <3 sec.
Peripheral pulses palpable. No edema. Sensation intact without numbness or paresthesia.
i. SURGICAL DRESSING/INCISIONAL ASSESSMENT - Dressing dry and intact. No evidence of redness, increased temperature,
or tenderness in surrounding tissue. Sutures/staples/steri-strips intact. Wound edges well-approximated. No drainage present.
j. PAIN ASSESSMENT - If medication alone relieves pain and expected outcome is met, documentation on the Medication Profile is
sufficient. No specific problem needs to be identified in the Nurses’ Notes or Flow Sheet.
k. POST-MYELOGRAM COMPLICATION ASSESSMENT - Absence of headache, nausea, and vomiting.
l. MYELOGRAM SITE ASSESSMENT - Steri-strip dry and intact. No drainage present.
5. Upon carrying out an order that has significant findings, an asterisk is entered in the appropriate box. An asterisk (*) in the category
box indicates to “See Significant Findings Section.”
6. If status remains unchanged from previous asterisk entry, current entry may be indicated with an “ .”
7. If an order no longer needs to be carried out, the next unused category box in that row indicates “order D/Ced,” and a line should be
drawn through the remaining boxes. Any unused rows can be left blank.
8. Each flow sheet is used for 24 hours.
FIGURE 7-6 Guidelines for the use of the nursing or physician order flow sheet. These guidelines appear on the reverse side of the first page of the
flow sheet.
Computerized provider order entry (CPOE) provides entered on the computer and then automatically
for efficient work flow because, when orders are posted to the electronic medication administration
entered into the computer, they are automatically record (eMAR) for that patient and to the pharmacy for
routed to the appropriate clinical areas for action. For the order to be filled. The order is always legible, and
example, a physician order for a new medication is transcribing errors are eliminated.
FIGURE 7-7 Physical assessment documentation on a nursing or physician order flow sheet, with significant findings noted.
In computerized charting systems, it is important to be made at the point of care, at the time a change in
have standard terminology appropriate for the entire condition is observed or a treatment is given. The
interdisciplinary team. The Systematized Nomencla- information is fresh, and no time has to be spent
ture of Medicine–Clinical Terms is a reference vocabu- recalling details or organizing events in sequence. If
lary developed for this purpose. This is important in the system uses a drop-down table or menu to select
evidence-based practice for researchers to understand from, you can quickly choose the appropriate descrip-
the relationships in the data to predict trends and con- tion or intervention and do not have to key in free
sequences of care (Lunney et al., 2005). text. Test and diagnostic results can be electronically
Health care agencies are moving toward electronic added to the medical record as they are received,
documentation of patient care. Documentation can be allowing for more rapid information flow between
done as interventions are performed with the use of a health care providers.
workstation on wheels (Figure 7-8) or a hand-held Computerized systems for charting vary. Any docu-
terminal carried from room to room. Computer- mentation system can be supported using electronic
assisted charting can save nursing time. Entries can documentation. Some organizations use a combination
Box 7-1 Tips for Computer Charting documentation of current data and provide space for
the addition of new findings. Much of the everyday
• Attend a computer documentation orientation held by care can be charted rapidly and completely in just sec-
the facility. Obtain a “quick reference guide.” onds using such screens. Often the progress notes from
• Determine the “superuser” on your unit to be used as a all disciplines involved in the patient’s care are inte-
resource.
grated. A chart of vital sign trends or laboratory value
• Refresh the computer screen often to keep track of the
most current medical orders and other health care
trends can be printed quickly. Figure 7-9 shows a print-
providers’ entries. out of part of a patient’s electronic chart.
• Chart in a timely manner. If an organization and medical community have
• Do not share passwords or computer codes. Your code fully implemented EHRs, clinical information from all
is your legal electronic signature. sources will flow into the record. This results in a lon-
• Review your notes for accuracy before you select gitudinal medical record that contains documentation
“confirm” or “save.” of all of a patient’s health care through time. The record
• Never walk away from your terminal without logging off. is divided into episodes of care. An episode of care can
occur in the outpatient or inpatient setting, any time
the patient received medical assessment and/or medi-
cal intervention. As mentioned earlier, laboratory
results, diagnostic imaging results, pathology reports,
medication administration, and other information
from all care delivery settings will be available via the
EHR. This provides virtually instant access to a com-
plete medical history.
At this time, fully integrated EHRs are not common.
There are multiple vendors for EHR systems. Integra-
tion of these systems with an agency’s current needs
requires computer programming and interfaces, which
can be expensive and time-consuming. Organizations
must invest significant time and money to develop a
true longitudinal EHR.
Most organizations using EHRs have a computer
system that collects health care information while the
patient is receiving either inpatient or outpatient ser-
vices. The inpatient and outpatient systems may be
integrated, allowing physicians to access all patient
information in the computer system from their offices.
However, the clinic medical record and the hospital
system’s medical record may still remain separate and
FIGURE 7-8 Nurse using a workstation on wheels at the bedside to require access to both computer systems to review.
do point-of-service charting. A major consideration when using an electronic
documentation system is confidentiality. Every indi-

of manual and electronic documentation. For example, vidual who accesses the medical record has a pass-
some documentation systems produce a flow sheet word that is necessary for access to the assigned
with the expected patient outcomes and nursing inter- patient’s chart. Based on her position or job code, the
ventions listed. The nurse initials those interventions person will be given a level of security that will allow
that were implemented, writes a narrative note for access to only the specific information required for the
other necessary information, and adds the printout job. When working on documentation at the com-
page to the chart. This adds some limited electronic puter, never leave the terminal while part of a
functions to a basically manual system. patient’s chart is on the screen. Situate terminals so
Other systems use the POMR format and produce a that passersby cannot view the information displayed.
prioritized problem list. A care plan is constructed by Organizations have specific policies outlining access,
selecting the diagnoses, expected outcomes, and nurs- security, and use of the EHR. Organizations often
ing interventions from specific screens on the com- require health care providers to sign nondisclosure
puter and keying in required information. A touch agreements (see Chapter 3) regarding confidential
screen may be part of the system for choosing items. patient information.
A third type of system consists of selecting data Electronic records provide vital information to
from display screens to build the flow sheets and prog- health care personnel instantly so they can immediately
ress notes. The display screens are structured to allow review previous problems, treatments, and responses.
cont’d
FIGURE 7-9 Example of part of a patient’s electronic chart.

Cultural Considerations • There is quick communication between depart-

ments about patient needs.
Helpful Specific Cultural Information • Multiple health care providers can access the
Including the following patient information can enable the same patient’s information at one time.
health care team to provide enhanced care: • It can reduce documentation time.
• Primary language spoken and communication needs (The • Electronic records can be retrieved quickly.
Joint Commission requirement) • Reimbursement for services rendered can be faster
• Head of family or spokesperson
and more complete because of complete and accu-
• Dietary differences and foods not permitted in the diet
• Ability to read and write in English
rate documentation.
• Beliefs about cause of illness • A true electronic medical record can provide a
• Special concerns related to religious/spiritual beliefs complete longitudinal record of the patient’s
• Individual needs for uninterrupted time for meditation or prayer medical history at one point of access.
• Well-designed systems can reduce errors, having

Advantages of computer-assisted documentation a positive impact on patient safety.

include the following: Disadvantages include the following:
• The date and time of the notation are automati- • A sophisticated security system is necessary to
cally recorded. prevent unauthorized personnel from accessing
• Notes are always legible and easy to read. patient records.
• Initial costs are considerable because many more the words “appears to” or “seems” in phrases such as
terminals and an appropriate networking system “appears to be resting.” Chart the behavior; the patient
must be purchased and interfaced for the system either is or is not resting. Words that have ambiguous
to work efficiently. meanings and slang should not be used in charting.
• Implementation of a full EHR system can take For example, how much is “a little,” “a small amount,”
considerable time. This results in the need to use or a “large amount”? What do phrases such as “ate
two systems, paper and electronic, during that well,” “taking fluids poorly,” and “tolerated well”
transition. mean? Although such words give a general idea of
• Significant cost and time are involved in training what is meant, they are not specific. Someone else
staff to use the system. reading the notes will not know if the patient who “ate
• Computer downtime can create problems of well” had a half a piece of toast, juice, and a cup of cof-
input, access, and transfer of information. Well- fee or ate a bowl of cereal, scrambled eggs, two slices of
established backup plans (downtime procedures) bacon, 4 oz of orange juice, and two cups of coffee.
must be developed. Instead of charting a conclusion such as “taking fluids
poorly,” chart the behavior and the specific amounts of
CASE MANAGEMENT SYSTEM CHARTING liquid taken in a particular amount of time, such as
Case management is a method of organizing patient “given fluids at frequent intervals, but takes only a few
care through an episode of illness so that clinical out- swallows; intake from 0700–1000: 30 mL of coffee, 60
comes are achieved within an expected time frame and mL of orange juice, and 50 mL of water.” Specific data
at a predictable cost (see Chapters 1 and 2). A clinical about size, amounts, and other measurements provide
pathway or interdisciplinary care plan takes the place a means for determining whether the condition is get-
of the nursing care plan. Documentation of variances is ting better, getting worse, or staying the same. Rather
placed on the back of the pathway sheets. For example, than use the term “tolerated well,” describe what hap-
a patient is admitted for abdominal surgery. The wound pened, even if it is a statement such as “walked in hall
is healing well, but the patient develops pneumonia. without problems.”
The variance would be documented as in Figure 7-10.
BREVITY IN CHARTING
Think Critically When charting, sentences are not necessary. Articles (a,
Which method of charting seems easiest to you? Can you an, the) may be omitted. Because the chart is about a
explain why? particular patient, the word “patient” is left out when-

ever it is the subject of the sentence. Each statement
should begin with a capital letter and end with a
THE DOCUMENTATION PROCESS
period. Rather than stating, “Patient left for surgery
When documenting patient care, present the patient’s via stretcher at 10:15,” simply state, “To surgery via
needs, problems, and activities in terms of behaviors. stretcher at 10:15.”
The notes focus on the immediate past and the present, Abbreviations, acronyms, and symbols acceptable
never the future. In other words, only chart what you to the agency are used in charting to save time and
have done for the patient, not what you plan to do. For space. Each agency has its own list of acceptable
example, after assisting a patient to ambulate, you might abbreviations and symbols. This list is usually found
chart, “Ambulated 20 feet down the hall and back.” in the policy and procedures manual. A list of com-
Charting should be accurate, brief, and complete. monly used abbreviations and symbols is provided in
When charting follows these guidelines, it presents a Appendix H.
photographic view of the patient to anyone who reads You must choose which behaviors and observations
the nursing notes. are noteworthy, or your nurse’s notes will be lengthy
and irrelevant. In most agencies, if data (such as patient
ACCURACY IN CHARTING voiding) are recorded on a flow sheet, they need not be
Be specific and definite in using words or phrases that documented again in the nurse’s notes. No other nota-
convey the meaning you wish expressed. Avoid using tion is made in the nurse’s notes unless there is a
Variation Cause Action Taken

Airway Pneumonia 7/23 ↑ fluids to 2000 mL/day
Clearance 7/23 7/24 Proventil inhaler for wheezing
7/24 Incentive spirometer use encouraged every 1° while awake
7/26 Instructed in home O2 use
7/26 Unit Air contacted for oxygen delivery
FIGURE 7-10 Example of variance charting.

problem or some significant related data. A good way General Charting Guidelines
to learn what should and should not be charted is to In addition to those mentioned above, there are sev-
read over the notes of experienced nurses who are eral other general rules to consider when charting
known to chart accurately and well. A rule of thumb is (Box 7-4). Figure 7-13 shows the use of regular versus
that if the behavior or finding is abnormal or a change military time for chart entries.
from previous behavior or data, chart it.
LEGIBILITY AND COMPLETENESS IN CHARTING THE KARDEX

Legibility is extremely important when charting. The The Kardex is a quick reference for current information
medical record may be called into court, and what you about the patient and ordered treatments, updated
wrote may be scrutinized and evaluated. If the writing daily. The Kardex is being phased out in many facilities
is not easily legible, misperceptions of what was writ- and being replaced by EHRs. When used, however, the
ten can occur. Kardex contains a separate card for each patient on a
Completeness is more important than brevity. You rotary spool that can be flipped through quickly. Each
should record information about the patient’s needs and card contains the following information:
problems and also specify the nursing care given for • Room number, patient name, age, sex, admitting
those needs or problems. If you chart, “Skin at IV site diagnosis, and physician’s name
reddened and slightly swollen,” you must include a note • Date of surgery
about what you did about the problem. The full note • Type of diet ordered
should read, “Skin at right forearm IV site reddened and • Scheduled tests or procedures
slightly swollen in 4-cm area. IV dc’d and warm moist • Level of activity permitted
pack applied for 20 minutes. Redness and swelling • Tubes, machines, and other equipment in use
receding. IV restarted in left hand with 20-ga catheter.” • Nursing orders for assistive or comfort measures
What constitutes complete charting may vary • Names of medications prescribed
among hospitals, extended-care facilities, and other • IV fluids ordered
health care agencies. Home care charting must par- Currently, instead of the Kardex, worksheets or
ticularly note safety factors in place and the need for working care plans are typically printed out for each
continued care (Figure 7-11). Long-term care facilities patient each shift from the electronic medical record.
may require only a monthly summary for patients in During shift report, the nurse assigned to the patient
stable condition or a note when their condition receives the printed sheet for that patient or reviews
changes (Figure 7-12), whereas hospitals caring for her electronic care plan. The unit secretary has a census
acutely ill patients require continual documentation sheet or an electronic census board listing the room
of the patient’s condition, with entries made every numbers, patient names, and diagnoses. For the com-
few hours. For completeness in charting about the puterized system, these sheets are automatically
patient’s signs or symptoms, note something about updated as new orders are entered into the computer.
each of the seven factors listed in Box 7-2. The patient care plans can be used to organize your
work and to record key nursing observations of the
WHAT TO DOCUMENT patient (e.g., noting the time at which PRN medica-
In addition to assessment data related to signs and tions are given, the amounts of intake and output, vital
symptoms, information on the topics in Box 7-3 is to be signs, and wound appearance). You should exercise
documented either on flow sheets or in the nurse’s caution when using printed care plans because,
notes. The charting examples included with the proce- although they were valid at the time they were printed,
dures throughout this book show how to describe dif- they will not reflect any subsequent changes to the
ferent types of information. real-time electronic medical record.
FIGURE 7-11 Example of home care agency charting.
Date/Time Licensed Nurses Progress Notes

4/15/13 Pt asked both nurses at med carts for IM injection Cortisone and “could I have meds right
7-3 shift now?” Instructed to take seat at breakfast table. Pt’s roommate called nurse. Pt supine on
floor no LOC. Walker at side A/O. Answered all questions appropriately, no ∆ in speech and
mentation.----------------------------------------------------------------------------------------------------
VS taken by this RN: T 98.6, P 76, R 16, BP 120/80.-------------------------------------------------
Denies HA, no s/s CVA/TIA- clear conversation, no paralysis. C/O right knee discomfort
when asked what heppened- why she fell. Assisted to chair. Denies pain. Neuro VS
unremarkable: PERL hand grips strong- no s/s hypoglycemia, no sweating or lethargy, alert,
gave complete date, answered questions appropriately. Reported to supervisor: Vivian Violet, RN DON.
------------------------------------------------------------------------------------------------------------M. Markham, RN
FIGURE 7-12 Example of long-term care facility charting.
Box 7-2 Guidelines for Charting About a Sign or a Symptom

Location in the body: Describe the exact location. Setting: Where is the patient (e.g., at home, in bed, in the
Quality: Describe in patient’s terms; for example, a person car), what is the patient doing (e.g., running, sleeping, eat-
having a myocardial infarction (heart attack) might ing), and who is the patient with (e.g., mother, spouse,
describe the chest pain as feeling like the chest is being boss) when the symptoms occur?
“squeezed in a vise.” Aggravating or alleviating factors: What makes the signs
Quantity: Chart the intensity of the symptoms (i.e., mild, or symptoms worse and what makes them better? Does
moderate, or severe). Use a scale of 1 to 10 for pain, with a hot shower make a skin rash worse? Does eating cause
10 being the highest. Indicate the degree of impairment more or less pain?
and the frequency, volume, and size or extent of the sign Associated manifestations: Signs and symptoms rarely
or symptom. Note the number of times the patient has occur singly. For instance, does the patient have nausea
vomited, amount each time, and whether nausea is con- before vomiting? Has there been a weight change since
stant or intermittent. the onset of vomiting?
Chronology: Note the sequence of development:
a. Time of onset of the sign or symptom
b. Duration (minutes, hours, days)
c. Pattern of variation and frequency and the course of the
signs or symptoms (e.g., Do they stay the same, get
better, or get worse over time?)
Box 7-3 Types of Information to Be Documented

• Admission note • Intake and output • Sleep
• Assessment data for all body systems • Intravenous infusions • Specimens obtained and their dis-
• Body care • Medications position
• Death • Mental state and mood • Teaching

• Degree of activity • Mood, concerns, or discomfort • Travel from the unit
• Diagnostic tests • Oxygen in use • Tubes and equipment in use
• Diet and fluids • Physician’s visits and calls to physician • Visitors
• Discharge from the facility • Postoperative care
• Dressings and wound care • Procedures performed
Box 7-4 General Guidelines for Charting

• Verify the name on the chart and the page before beginning to chart. Each page should have an imprint of the patient’s name
and hospital number on it. For EHR documentation, verify you are on the correct patient’s computer screen.
• Chart the initial assessment at the beginning of the shift.
• Preferably use black ink; blue may be acceptable in your agency.
• Place date at beginning of day’s entries and time each entry; use either a regular clock or a 24-hour clock (military time; see
Figure 7-13).
• Charting is done only by the person who made the observation or performed the intervention and who is legally responsible
for the accuracy and quality of care.
• Write legibly or print.
• After the note is complete, sign with one initial plus last name and title (e.g., J. Jones, LPN; M. White, SVN). Many agencies
ask students to add “student” or their school initials behind their title.
• Chart objective data after completing each task. Nothing is ever charted before it is actually done.
• No blank lines are left in the charting. Draw a horizontal line through the center of an empty line or part of a line. Draw a line
through a space or write “N/A” (not applicable) if information asked for on forms does not apply to the patient. For EHR docu-
mentation, follow hospital policy for amending the record.
• A late entry may be made if something has been forgotten. Write the time of the entry, circle it, and write “late entry” and your
initials above the time.
Example of a late entry:
8/22/13 0900 #2 Voided 450 mL clear, straw-colored urine. States no “burning,
urgency,” or ↑ frequency of voiding.----------------------------------
0930 #2 Amb to door of room and back c assistance. States caused no
pain.------------------------------------------------------------------------------
0945 Late entry for Clean catch urine collected and sent to lab for UA.--J. Biggs, LPN
0900
• Clearly identify care given by another health care team member.

• When a patient refuses a medication, place a circle on the medication administration record around the time the medication
was to be given, and record an explanation for the refusal in the progress notes. Any refusals of treatments are also recorded
in the chart. The exact words the patient uses when refusing to comply with the treatment regimen should be documented.
Document any instructions given to the patient and any patient behaviors that are against the instructions.
• Spell chart entries correctly. Use a dictionary to check words you are unsure how to spell.
• Use only ink on the medical record. Entries should never be erased or obliterated with liquid correction fluid. Deleted entries
may be questioned if the chart is used later in a court of law. If you suspect that a medical order or progress note is incorrect,
seek clarification from the person who wrote the order or the note. If you make an error when charting, draw a line through the
incorrect word or phrase and write the word “error” above it; add the date and your initials. Some agencies require the words
“mistaken entry” or “incorrect entry” rather than “error.”
Example of error correction:
2400
2300 1300
12:00
11:00 1:00
2200 1400
10:00 2:00
2100 9:00 3:00 1500
8:00 4:00
1600
2000
7:00 5:00
6:00
1900 1700
1800
FIGURE 7-13 Military time versus civilian time.
Get Ready for the NCLEX® Examination!
Key Points • C omputer charting is expensive to institute but saves

considerable nursing time.
• D ocumentation provides a communication tool for the • Case management system charting tracks variances
health care team; maintains a written record of the from the care map.
history, care, and treatment of the patient; is a legal • Documentation should show the application of the
record; is a quality assurance tool; and provides a basis nursing process, and present a snapshot of the patient’s
for reimbursement of services. condition and care.
• The nursing care plan is the framework for nursing • Charting must be objective, accurate, brief, and complete.
documentation. • Chart the patient’s behaviors and statements, not your
• Evaluation data that are documented must show opinions or conclusions.
progress toward expected outcomes. • The list of activities and data that must be charted about
• Information in the medical record must be kept confi- the patient each day is extensive.
dential, and only those health professionals directly • Guidelines for charting tell the nurse when, what, and
involved in the patient’s care should have access to the how to document patient assessments, activities, and
record. interventions.
• There are six main methods of charting: (1) source-
oriented (narrative) style, (2) POMR style, (3) focus
charting, (4) charting by exception, (5) computer- Additional Learning Resources
assisted charting, and (6) case management system

charting.
SG Go to your Study Guide for additional learning activities to help you
• Besides nurses’ and physicians’ progress notes, many master this chapter content.
flow sheets are used to document patient information.
• An advantage of the source-oriented method is that Go to your Evolve website (http://evolve.elsevier.com/deWit/
information on the patient’s condition and care is listed in fundamental) for the following FREE learning resources:
chronologic order. • Animations
• An advantage of the POMR system is that it improves • Answer Guidelines for Think Critically boxes and Critical Thinking
continuity of care by keeping data relevant to a problem Questions and Activities
all in one place. • Answers and Rationales for Review Questions for the NCLEX® Examination
• An advantage of focus charting is that it shortens • Glossary with pronunciations in English and Spanish
charting time by using many flow sheets and checklists. • Interactive Review Questions for the NCLEX® Examination and more!
• Although charting by exception highlights abnormal data
and patient trends, it presents problems if called into Online Resources
court because only abnormal findings are documented in • Informatics KSAs for prelicensure nurses, www.qsen.org/ksas_prelicens
writing. ure.php#informatics
Review Questions for the NCLEX® Examination 7. The advantage of POMR charting when using an
interdisciplinary care system is that:
Choose the best answer for each question.
1. all charting is done on flow sheets.
1. The nurse has misplaced her computer password. She 2. not as many flow sheets are used.
asks if she can borrow yours “just for a moment” to 3. it keeps all relevant data in one place.
view patient data and promises she will not document 4. nurses have to chart only on flow sheets.
anything. Your best course of action is to:
8. The assumption in charting by exception is that:
1. allow her to use your password, just this once.
2. sit with her and access the data together. 1. if it was not charted, it was not done.
3. inform her to contact the IT Department to obtain a 2. patient care is charted chronologically.
new password. 3. unless otherwise documented, all standards have
4. tell her you’re busy, and to ask someone else. been met.
4. a SOAPIER format note must be made each shift.
2. Which is the most precise example of appropriate
charting? 9. An advantage of computer charting is that:
1. “Aggressive and combative during a.m. care.” 1. computers are always up, running, and available.
2. “Received 250 mL tube feeding during shift, toler- 2. security of information is guaranteed with the
ated well.” computer system.
3. “Ambulated 2X during shift, 50 ft with assistance of 3. others can see what is being input as the nurse
one. Pre-activity vs: 85, 18, 110/70; post-activity vs: works with the charting screens.
95, 22, 120/76.” 4. it is cost-effective because it saves nursing time
4. “Ambulated to nurses station and back, tol well.” compared with writing out notes.
3. Patients frequently request copies of their medical 10. When charting the patient’s condition and nursing care,
records. You understand that: the nurse records: (Select all that apply.)
1. they have a right to a copy of their record after 1. activities planned for a later date.
discharge. 2. goals for the medical treatment and evaluation.
2. only health care staff have the right to read the 3. the interventions performed and the patient’s
record. responses.
3. the patient and family have a right to read the record. 4. patient statements and behaviors that are observed.
4. the physician must write an order for the release of 5. clinical data measurements.
the record.
4. One characteristic differentiating source-oriented Critical Thinking Activities

(narrative) charting from POMR charting is: Read each clinical scenario and discuss the questions with
1. a specific order of forms in the chart. your classmates.
2. a focus on the patient’s problems.
3. the separation of notes on medical care and nursing Scenario A
care. Read the following scenario and then write out a POMR
4. patient identification stamped on each form. progress note and a focus charting note using the data
given.
5. When charting, it is wise to always: Marvin Barnes was admitted with the diagnosis of
1. include the names of all visitors with the time of the Impaired gas exchange r/t excessive pulmonary secretions.
visit. When you go to assess him, you discover that his tempera-
2. check that you are on the right chart or screen and ture is 102.6° F (39.2° C), pulse 77 beats/min, respirations
on the right date. 26 breaths/min and shallow, and blood pressure 147/92
3. sign your full name, date, and time on each sheet. mm Hg. He is coughing and produces yellow-green
4. use acronyms you are familiar with to shorten notes. sputum. He is having difficulty stopping the cough. He has
oxygen via nasal cannula running at 3 L/min. He has
6. When a patient’s medical record is needed as evidence acetaminophen ordered for fever over 100.2° F (37.9° C).
for a legal action, you are aware that the record is the You tell him that you will be back with medicine for his fever
property of: and that you will call the physician for an order for some
1. the patient. cough medicine to relieve the cough.
2. the patient’s lawyer.
Scenario B
3. the court.
Discuss the guidelines that will help you chart so that you
4. the health care agency.
would be protected if there were a lawsuit involving a
patient to whom you had given care.
chapter
Communication and the

Nurse-Patient Relationship
8
Objectives
1. Describe the components of the communication process. 1. Use interviewing skills to obtain an admission history from
2. List three factors that influence the way a person commu- a patient.
nicates. 2. Interact therapeutically in a goal-directed situation with a
3. Compare effective communication techniques with blocks patient.
to communication. 3. Communicate effectively with a patient who has an
4. Describe the difference between a therapeutic nurse- impairment of communication.
patient relationship and a social relationship. 4. Give an effective report on assigned patients to your team
5. Discuss the importance of communication in the collabora- leader or charge nurse.
tive process. 5. Be present and nonjudgmental when communicating with
6. List three guidelines for effective communication with a patients, and be mindful of their needs.
physician by telephone.
7. Identify four ways to delegate effectively.
8. Discuss five ways the computer is used for communication
within the health care agency.
9. Describe how communication skills can affect the quality
and safety of patient care.
Key Terms
active listening (p. 100) ISBAR-R (p. 110)
advocate (p. 101) mindful (p. 100)
aphasia (ā-FĀ-zē-ă, p. 108) nonverbal (NŎN-vĕr-bŭl, p. 99)
body language (p. 99) nonjudgmental (p. 101)
communication (kŏ-myū-nĭ-KĀ-shūn, p. 99) patient-centered care (p. 101)
confidentiality (kŏn-fĭ-dĕn-shē-ĂL-ĭ-tē, p. 107) perception (pĕr-CĔP-shŭn, p. 100)
congruent (kŏn-GRŪ-ĕnt, p. 99) rapport (ră-PŌR, p. 106)
delegate (DĔ-lĕ-gāt, p. 110) shift report (p. 109)
empathy (ĔM-pă-thē, p. 107) therapeutic (thĕr-ă-PYŪ-tĭk, p. 103)

feedback (p. 100) therapeutic communication (p. 102)
incongruent (ĭn-kŏn-GRŪ-ĕnt, p. 101) verbal (VĔR-bŭl, p. 99)
input (p. 111)
THE COMMUNICATION PROCESS spoken or written. Nonverbal communication, also

Communication occurs when one person sends a mes- known as body language, is conveyed by gesture,
sage to another person who receives it, processes it, expression, body posture, intonation, and general
and indicates that the message has been interpreted appearance. Nonverbal communication conveys more
(Figure 8-1). The receiver must acknowledge that the of what a person feels, thinks, and means than is actu-
message has been received and comprehended for ally stated in words (Figure 8-2). Sometimes the per-
communication to be complete. By its nature, commu- son’s nonverbal communication is not congruent (in
nication is a continuous, circular process and occurs in agreement) with the verbal communication. If you
two ways: verbal (in words) and nonverbal (without state that you want to sit and talk for a while and then
words). Verbal communication consists of words either sit with legs crossed and a foot bouncing rapidly
99
Good communication requires active listening

Message (focusing on what is being said), timely feedback
(return of information and how it was interpreted),
and validation of assumptions about nonverbal cues.
“Help me move you up in bed by

bending your knees and placing
Clinical Cues
Sender Receiver
your feet flat on the bed.” Giving positive feedback increases the likelihood that a desired
behavior will be repeated. For example, you are trying to get
Mrs. Panopoulos to independently perform activities of daily
Feedback living. “Mrs. Panopoulos, I saw you combing your own hair
this morning. (State the observed behavior.) I really liked the
Validation
way that you styled it. (Give praise.) Keep up the good
work!” (State the desired behavior.)

“You mean put my feet like this?”
Sender Receiver FACTORS AFFECTING COMMUNICATION
FIGURE 8-1 The communication process.
Culture, past experience, emotions, mood, attitude,
perceptions of the individual, and self-concept all con-
tribute to the way people communicate. Every culture
has norms for appropriate communication. The norms
include the distance between communicators, whether
eye contact should be established, the tone of voice,
and the amount of gestures used. The physical envi-
ronment and the person’s comfort level can also influ-
ence the ability to receive and process the information.
It is important to be mindful (highly aware and alert) of
each individual’s style and needs.
Cultural Differences
Individuals differ in the amount of personal space
they need between them and the person with whom
they are speaking. In the United States, 18 inches to 4
FIGURE 8-2 Nonverbal communication signals that the nurse is feet is the distance that individuals generally place
interested in the patient and what she is saying. between themselves and a new acquaintance. This
distance is called personal space. The distance lessens
during the conversation, the message is one of impa- when people converse with someone with whom they
tience rather than attentive listening. are intimate. When people are not acquainted, they
maintain a social distance of 4 to 12 feet if they have a
Think Critically choice. In general, American Indians, northern Euro-
peans, and Asians maintain more distance from oth-
Look at Figure 8-2. Identify six or seven examples of nonverbal
communication that the nurse is using in this nurse-patient ers than do Hispanic, southern European, or Middle
depiction. Eastern people.

You can learn about patients by observing nonver- Cultural Considerations

bal behavior. Anxiety, fear, and pain are often
Eye Contact
expressed by nonverbal cues. Wincing when turning,
a pinched expression, or picking at the bed covers may Most Americans expect direct eye contact when interacting
with someone; other cultures—for example Japanese, Chi-
indicate what patients are really feeling, although they
nese, Vietnamese, and Laotians—may consider it rude to look
say they are fine. Rigid body posture or slow move-
directly at someone. For Jamaicans, direct eye contact toward
ments often indicate pain. Restless movements may an authority figure or between strangers may indicate a chal-
indicate anxiety. Experience will increase your ability lenge. Learn how eye contact is used in your patient’s culture
to assess nonverbal communication. Validate percep- by observing how your patient interacts with others. Find
tion (recognition and interpretation of sensory stimuli) opportunities to talk with colleagues from different cultures to
of nonverbal communication with the patient. This learn about eye contact and other communication nuances.

can be done by asking about feelings and thoughts.
For, example, “Mrs. Lopez, you seem a little restless Past Experience
[and anxious] today. Would you like to talk about All of our experiences affect how we perceive commu-
something?” nication. Interpretation of messages is influenced by
Communication and the Nurse-Patient Relationship CHAPTER 8 101
cultural values, education, familiarity with the topic, Active Listening

occupation, and previous life experiences. Active listening requires great concentration and
focused energy. All the senses are used to interpret ver-
Think Critically bal and nonverbal messages, attention is on what the
You are with Mrs. Ito and the physician walks in and says, “A
speaker is saying, and the mind is focused on the inter-
cardiac catheterization needs to be done to see if the coro- action. Listen for feelings as well as words. It takes
nary arteries are blocked.” The patient has limited experience practice to tune out other thoughts that try to intrude
with hospitalization and medical terminology. She shyly looks and to avoid formulating a response until the speaker is
down at her hands. It is unclear if she understands. What finished. When you are an active listener, you demon-
could you do?

strate interest, and a trusting relationship can be built.
An active listener maintains eye contact without star-
Emotions, Mood, and Environment ing, gives the patient full attention, and makes a con-
Emotions and mood can drastically affect the way scious effort to block out other distractions. An active
messages are sent or interpreted. A highly anxious listener does not interrupt, and waits for the full mes-
person may not correctly hear what is said or may sage before interpreting what is said. Responding to the
interpret the message totally differently than the content and feelings of the message by stating what
sender intended. A depressed person tends to use you, as the listener, understand was said by the patient
few words. A person who is upset or stressed may completes the process. Nonverbal cues that indicate
speak in a loud, harsh tone or be more abrupt than active listening are leaning forward, focusing on the
usual. Remember, most patients are in a hospital envi- speaker’s face, nodding slightly to indicate the message
ronment, away from home, often sleep deprived with is being heard, and maintaining an open body posture.
some level of pain. By recognizing emotions and
moods, keeping patients as comfortable as possible, Interpreting Nonverbal Messages
and frequently obtaining feedback, misunderstand- The speaker’s posture, gestures, tone, facial expression,
ings can be reduced. and eye movements should be observed. A smile or
frown, hunched-down posture, and hand-wringing all
Attitude, Perceptions, and Self-Concept express feelings. When taking in nonverbal messages,
A person’s attitude, perceptions, and self-concept remember that they must be interpreted in the context
affect how a message is worded and the body language of the speaker’s culture, not the listener’s. The listener
that accompanies it. When your attitude is one of must decide whether the nonverbal messages are con-
acceptance of the patient, caring and concern are dis- gruent with the spoken message. Mixed messages, in
played by open, attentive body language. If you have a which the verbal and nonverbal messages are incon-
negative perception of and disapprove of the patient’s gruent (do not agree), require the listener to explore
behavior, you may use a closed body stance and stern what the speaker really wishes to communicate.
expression and be somewhat distant during interac-
tions. Someone with an accepting attitude will make Clinical Cues
an effort to understand what a person is trying to con-
Laughing, smiling, and appropriate use of humor can decrease
vey during the communication by being present stress and anxiety and have a positive effect on the immune
(focused on the moment) and being an advocate (rep- system (Hasan and Hasan, 2009). Encourage and support
resentative) for their needs. your patient’s efforts to smile and be positive; however, be sen-
Try to be open and attentive to patients’ communica- sitive to incongruent behaviors. If you think your patient is smil-
tions, to maintain a nonjudgmental (refraining from ing to cover her fears or anxieties, provide openings for her to
judgment) attitude, and to not take personally anything express her true feelings.

unpleasant a patient says when upset or frightened.
COMMUNICATION SKILLS Elder Care Points

Some people are more effective communicators than When interacting with an elderly person, try not to speak too
others. Effective communication can be learned by quickly. Allow more time for the person to process your mes-
sage and formulate a response. Many elderly people have
practicing and improving basic communication skills.
some degree of hearing loss. Face the person so that your lips
Nurses must have knowledge of the principles of can be seen and she has the best chance of hearing your
effective communication, implement the skill of com- words. If the person wears a hearing aid, be certain it is in place
municating effectively, and possess the attitude of and turned on.
wanting to improve communication skills. Patient-
centered care, with the patient as the focus, is essential

in providing compassionate and coordinated care Obtaining Feedback
based on respect for patient preferences, values, and A vital part of communication is checking to see if you
needs (QSEN, 2010a). interpreted a message correctly. You can do this by
rephrasing the message or directly asking a feedback will encourage the patient to verbalize feelings or
question, such as “Is your headache severe?” “Are you thoughts.
uncertain about having this surgery?” or “Does the
idea of having anesthesia scare you?” The response Clinical Cues
received should verify whether the original message If you are having trouble using silence, remember you are not
sent was interpreted correctly. passively waiting for the patient to speak. Observe nonverbal
behaviors during this silence. Note the patient’s body position
Focusing (e.g., relaxed, tense), expression on the face (thoughtful, sad),
Keeping the patient’s attention focused on the commu- conditions of the environment (presence or lack of personal
nication task at hand can save time. The effective com- items), and indicators of emotional duress (picking at nails,
municator refocuses the other person gently to the restless movements). These observations provide a significant
issue at hand when the focus has wandered. Occasion- amount of objective data.

ally the approach, “We’ll come back to that later, but

right now I need to know…” will quickly refocus the OPEN-ENDED QUESTIONS
communication. At other times, commenting, “I think An open-ended question is broad, indicating only the
we were talking about…” is what is needed. topic, and it requires an answer of more than a word or
two. An open-ended question allows the patient to
Adjusting Style elaborate on a subject or to choose aspects of the sub-
Consider the patient’s style and level of usual commu- ject to be discussed. Open-ended questions or state-
nication when interacting. If the person is a slow, calm ments are helpful to open up the conversation or to
communicator, adjust to that pace. If a response is slow proceed to a new topic. They usually cannot be
in coming, allow plenty of time for response; try not to answered with one word or just “yes” or “no.” “Tell
display impatience. If it is comfortable for the patient me about your day” versus “Did you have a good
to display feelings only in the context of telling a story day?” or “How did you sleep?” versus “Did you sleep
about a related topic, allow enough time for full devel- well?” are examples of open-ended versus closed ques-
opment of the topic so that the feelings can be ade- tions. The closed question forces the listener to stick
quately expressed. directly to the topic and to be concise. Open-ended
questions create an inviting atmosphere for sharing
Cultural Considerations thoughts, feelings, and concerns.
Conversational Pace and Flow
Clinical Cues
Long pauses are a natural part of conversation in some cul-
tures. This is often found among Native Americans. Do not be Closed questions are usually not considered part of the thera-
too quick to assume the speaker is finished. Among some cul- peutic communication process; however, at times, closed
tural groups, giving a direct “no” answer is considered rude, so questions are appropriate: when you are gathering information
maintaining silence means “no.” This may be true of those (“Have you ever had a blood transfusion?”), if the patient is
raised in a Japanese family. Often it is necessary to “give per- highly anxious (“Are you hurt?”) or confused (“Do you need to
mission” to ask questions. Certain groups regard asking ques- go to the toilet?”), or if the patient is at a young developmental
tions as rude or disrespectful. age (“Would you like the red one or the blue one?”).

THERAPEUTIC COMMUNICATION TECHNIQUES RESTATING

Therapeutic communication (communication that is Listen for the basic message the patient is conveying,
focused on the patient needs) promotes understanding then rephrase the heart of the message. If the patient
between the sender and the receiver. Various phrases states, “My son hasn’t been to see me in months,”
or cues may be used to promote understanding or responses that restate the thought in different words
facilitate an interaction between a patient and the might be as follows: “Your son hasn’t been around
nurse. These techniques should be used judiciously much lately,” or “You miss your son’s visits.” Restat-
and in a varied manner or the interaction will feel ing is used to encourage the patient to continue with
stilted and uncomfortable (Table 8-1). information on a topic.
Reflection is another way to restate the message.
SILENCE The same words the patient has said are reflected back.
Appropriate use of silence is one of the hardest tech- A patient says, “I’m worried about cancer,” and the
niques for most students to develop. The new nurse nurse replies, “You are worried about cancer.” The
is often uncomfortable with silence, and so tends to idea is simply reflected back to the speaker in a state-
be too quick to end it. Silence gives the patient time ment to encourage continued dialogue on the topic.
to think and respond. Remain attentive and use Restating and reflection should be used sparingly
body language indicating patience and interest; this and skillfully. If overused, the patient will quickly
Table 8-1 Therapeutic Communication Techniques

TECHNIQUE EXAMPLE RATIONALE
General leads “Go on.” “I see.” “Uh huh.” “Please continue.” Encourages patient to continue or elaborate.
Open-ended questions or “Tell me more about that feeling.” “I’d like to hear Encourages patient to elaborate rather than
statements more about….” answer in one or two words.
Offering self “I’m here to listen.” “Can I help in some way?” Shows caring, concern, and readiness to
help.
Restatement Patient says, “I tossed and turned last night.” Restates in different words what the patient
Nurse says, “You feel like you were awake all said; encourages further communication
night.” on that topic.
Reflection Patient says, “I’m so scared about the surgery; Reflects received message back to patient.
anesthesia terrifies me.” Also encourages further verbalization of
Nurse says, “Something scares you about feelings.
anesthesia?” Reflects feelings. Can also be used if patient
Patient looks scared. is unable to verbalize or if nonverbal
Nurse says, “You look scared.” information is incongruent with verbal.
Seeking clarification Patient says, “Having my little girl come to visit Seeks clarification about the source of the
me was so hard. I’m so upset.” Nurse says, upset feeling. Helps the patient clarify
“Something about your daughter’s visit upset thoughts or ideas.
you?”
Focusing “Do you have any questions about your Asking a goal-directed question helps the
chemotherapy?” patient focus on key concerns.
Encouraging elaboration “Tell me what that felt like.” “I need more Helps the patient describe more fully the
information about that.” “Tell me more about concern or problem under discussion.
that experience.”
Giving information “The test results take at least 48 hours.” “You will Provides the patient with information relevant
get a preoperative injection that will make you to specific health care or situation.
sleepy before you are taken to the operating
room.”
Looking at alternatives “Have you thought about…?” “You might want to Helps patients see options and consider
think about….” “Would this be an option?” alternatives to make their own decisions
about health care.
Silence Patient says, “I don’t know if I should have Allows patient time to gather thoughts and
chemotherapy, radiation, or both.” Nurse sort them out.
remains silent, sitting attentively but quietly.
Summarizing “You’ve identified your alternatives pretty clearly.” Sums up the important points of an
“You are aware of the important signs and interaction.
symptoms to report to your physician; you plan
to call to make an appointment next week.”
recognize that you are repeatedly saying her words TOUCH

back to her, which is annoying. Gentle touch indicates caring is therapeutic (effective
or curative). It may be used to signify support for the
CLARIFYING person or when appropriate words are hard to find.
Clarifying helps verify that the message heard is Use touch judiciously, and take into consideration the
what the patient intended. It is particularly useful patient’s cultural and personal feelings about being
when the dialogue has rambled. If a patient says touched by a stranger. You should have verbal or
that family members visited and that they all sat implied permission from the patient for touch to occur.
around and drank coffee, and then says that sleep- Messages accompanied by touch can add a feeling of
ing was difficult last night, the nurse might say, “Are caring and comfort. Touching the patient warmly on
you saying that the coffee kept you awake?” This the shoulder and saying, “I’m glad the medicine has
asks for confirmation that it was the caffeine in the relieved your pain” indicates caring. Touch must be
coffee that prevented sleep, and not a problem beneficial for the patient; it should not be done to meet
brought in by the family that might have caused the the nurse’s needs. Consider how the patient will per-
sleeplessness. ceive and interpret touching before implementing it.
patient in looking at alternative solutions to a problem.

Cultural Considerations Some helpful leads for this purpose are “You might
Using Touch to Communicate think about…,” “Have you thought of your options?”
or “What might be possible solutions?” The focus is on
Some cultures are more accepting of touch within the health
care setting. For example, a Portuguese patient may interpret helping patients look at things from their point of view
touch as reassuring. For the patient from Mexico, it may be while you refrain from giving advice.
advisable to touch while you are giving a compliment to neu-
tralize the power of the “evil eye.” Koreans traditionally hug and SUMMARIZING
touch family members or close friends, but touching from Summarizing what has occurred during the interac-
strangers is considered disrespectful unless for physical exam- tion is helpful. A summary of alternative solutions to a
ination purposes. Touching during communication is also problem, decisions made, plans for action, or feelings
uncommon in the Japanese culture. that have been expressed provides closure. “You’ve

indicated that you have a choice between undergoing

GENERAL LEADS surgery and trying medication for your problem.
Use general leads to get the interaction under way. If a We’ve discussed the potential side effects and benefits
patient says, “I feel guilty for breaking my leg,” a gen- of both treatments, and now you’d like time to think
eral lead would be, “Tell me more about that.” General about it” would be a summarizing statement.
leads cannot be answered with “yes” or “no” and
require more than a few words in response. “Perhaps Clinical Cues
you’d like to talk about your chemotherapy,” “I noticed
To improve your therapeutic communication skills, you have to
the doctor came after I left yesterday; perhaps you’d practice. Your instructor may ask you to do a process record-
like to talk about what he said,” and “I hear you are ing. Practice your skills with a real patient, then analyze and
being discharged today; what do you think about think about the patient’s behavior and your response. (See the
that?” are other examples. Evolve website for a sample process recording.)

OFFERING OF SELF
Being available to the patient is one way of offering
yourself. Answering call lights quickly or checking on
BLOCKS TO EFFECTIVE COMMUNICATION
something immediately states that you are available to Just as some phrases and cues encourage effective
the patient, but this is not always possible. Letting the communication, other phrases or cues tend to block or
patient know when you will return or when you will terminate interaction. Table 8-2 summarizes blocks to
obtain the desired information conveys availability. effective communication.
Fulfilling such promises helps establish trust. Another
form of offering yourself is to tell the patient, “I’ll just sit CHANGING THE SUBJECT
here with you for a while,” and remain with the patient. When a patient is speaking and you change the subject,
it indicates discomfort, disinterest, or anxiety on your
ENCOURAGING ELABORATION part. You are avoiding listening to a patient’s pain, dis-
Statements such as “You said you have had a difficult tress, fear, or perception of problems. If you change the
time these last few months” or “Tell me more” encourage subject in an effort to keep the patient’s thoughts off
the patient to share feelings. “I’m not certain that I follow unpleasant things, you deny the patient’s desire to
what you mean” is another way to encourage the patient express feelings. Sometimes the patient will talk about
to continue. Encouraging elaboration is used when an experience that is similar to something that hap-
more information is needed about a topic. This tech- pened to you. It is tempting to relate your experience,
nique might be used rather than restatement or reflection. directing the conversation away from the patient. Stu-
dents often make this mistake. Over time, you’ll learn
GIVING INFORMATION to consider whether the information is of real value to
Nurses must give patients information about medica- the patient before sharing your personal experiences.
tions, procedures, diagnostic tests, and self-care. Giv-
ing information concisely and allowing time OFFERING FALSE REASSURANCE
for questions is therapeutic for the patient. Giving too Giving reassurance not based in fact is damaging
much information can be confusing. Pay attention to because it discounts the patient’s concerns and destroys
nonverbal signals and ask for feedback to verify that trust. Saying “Don’t worry; everything is going to be
the patient has understood the information given. fine” when a patient has valid concerns indicates a lack
of understanding. The nurse who tells a woman who
LOOKING AT ALTERNATIVES has just had breast surgery that she should not think
Nurses help patients solve problems. To accomplish that her husband will find her scar distasteful because
this, they are sometimes directive in assisting the she is “still a beautiful woman” is offering inappropriate
Table 8-2 Blocks to Effective Communication

TECHNIQUE EXAMPLE RATIONALE
Changing the subject Patient says, “I’m so worried about my Deprives the patient of the chance to
husband.” Nurse says, “It is time for your verbalize concerns.
bath now.”
Giving false reassurance “I’m sure it will turn out fine.” “You don’t need to Negates the patient’s feelings and may give
worry.” false hope, which, when things turn out
differently, can destroy trust in the nurse.
Judgmental response “I don’t think that was a good thing for you to do Nurse is judging the patient’s action. Implies
considering you have diabetes.” that the patient must take on the nurse’s
values and is demeaning to the patient.
Defensive response Patient says, “My doctor never seems to know Nurse responds by defending the doctor.
what is going on.” Nurse says, “Dr. Smith is a Prevents patients from feeling free to
very good doctor; he’s here every day.” express their feelings.
Asking probing questions “Why were you there at that hour?” “What did Pries into the patient’s motives and therefore
you intend to prove?” invades privacy.
Using clichés “Cheer up, you’ll be home soon.” “This won’t Negates the patient’s individual situation;
hurt for long.” “You have a long life ahead of stereotypes the patient. This type of
you.” response sounds flippant and prevents the
building of trust between patient and nurse.
Giving advice “If I were you, I would….” “I think you should….” Tends to be controlling and diminishes
“Why don’t you….” patients’ responsibility for taking charge of
their own health.
Inattentive listening Turning your back when the patient is sharing Indicates that the patient is not important,
feelings or pertinent information; showing that the nurse is bored, or that what is
impatience with body language (e.g., tapping being said does not matter.
your foot or having your hand on the door to
go out).
reassurance about someone else’s feelings. This type of DEFENSIVE COMMENTS

comment conveys the message that you do not care Becoming defensive when a patient has a complaint
about the patient’s fears and feelings about her new interferes with effective communication. If a patient
body image and jeopardizes the professional relation- complains that the call light is not promptly answered in
ship. Reassurance should be based on fact. Informing a the evenings and you state, “You should realize how
patient that there will be some discomfort after a diag- short-staffed we are in the evenings,” the patient is
nostic procedure but analgesic medication will be avail- denied the right to a valid view and complaint. By tak-
able to relieve the discomfort is better than saying that it ing a position opposite to the patient’s point of view, you
is a simple procedure and not to worry. A realistic take on the role of adversary rather than helper.
approach helps maintain trust. Acknowledge the patient’s feelings by saying something
like, “It’s upsetting when no one can get here promptly.”
GIVING ADVICE
Giving advice is another area that prevents many nov- PRYING OR PROBING QUESTIONS
ice nurses from being therapeutic. Giving advice Probing questions may place the patient on the defen-
places the focus on the nurse rather than the patient. sive. This occurs when you ask questions about the
Also, many patients think that they must do what you patient’s private business, and these questions have no
say because you are the authority figure. Your role is to relation to the treatment or clinical condition. Ques-
guide patients to alternative choices for solving their tioning why the patient did or did not do a particular
own problems. thing makes the patient defensive about the action and
causes feelings of discomfort. If you ask a patient who
has been injured in an automobile accident, “Why
Clinical Cues
were you driving so fast in the rain?” you are inappro-
Do not use phrases such as “Why don’t you . . . ,” “When that priately probing.
happened to me, I did . . . ,” or “I think you should . . . .” Rephrase
to help the patient explore various alternatives. For example, USING CLICHÉS
“Have you thought of your options?” or “You might want to
A cliché is an overused expression that may have no
think about . . . ,” or “Have you considered . . . ?”
relation to the current situation. Comments such as
“You’ll be fine,” or “Don’t worry, it will turn out OK,” Communication

are clichés. They show a lack of respect for the patient
as an individual and discount the patient’s feelings. It Establishing Rapport
is better to express that you are available to listen to the To establish rapport with a patient so that you can proceed
patient’s concerns and feelings and to be supportive as with the interview or therapeutic interaction, you might use
needed. a few of these phrases:
• “Hello, Mr. Sanchez, I’m John; I’d like to know more about
INATTENTIVE LISTENING you. Can you tell me a little about what you do for a living [or
did before you retired]?”
Failing to really listen to what the patient is saying is a • “Mrs. Jackson, I see that you live alone. Can you tell me a
communication block. If you continue to straighten the little about your friends and activities?”
room and turn away while the patient is trying to • “Ms. Lee, you’ve had a lot happen to you over the past few
express feelings or something of importance, your weeks; it must be hard to have your life interrupted this way.”
actions express that you are not interested. Interrupt- • “Janice, your mom says you play basketball. It must be hard
ing or jumping in before the patient has finished not being able to play during this part of the season.”
speaking, or frequently changing the subject, also • “Joey, it’s OK to be angry and cry when you’ve been hurt.
indicates inattentive listening. Can you tell me how your leg feels now?”

Think Critically
When obtaining a health history during an admis-
Observe nurses in the hospital as they communicate with
patients. What types of blocks to communication do you see sion interview, take control of the interaction and ini-
occurring? Speculate as to why these nurses are blocking tially ask closed questions that call for specific data.
communication with their patients. This type of direct interview does not allow the patient
to ask questions or discuss concerns until all the neces-

sary information has been collected. Examples of ques-

tions might include the following:
INTERVIEWING SKILLS
• What medications did you take today?
An interview is more directed than a therapeutic com- • Do you have pain?
munication interaction. It is planned and has a definite • Do you have any allergies?
purpose. It is important to establish rapport (a relation- • If you have been hospitalized before, what year
ship of mutual trust) with the patient before beginning was it?
an interview. Introduce yourself and ask how the After taking the history, use open-ended questions
patient wishes to be addressed. Include the family in to find out how the patient feels about the hospitaliza-
your greeting. Explain the purpose of the interview tion. Examples of useful open-ended questions include
and provide privacy. Ask patients if they wish their “What brought you to the hospital?” “What are your
family or friends to remain during the interview by concerns about this hospitalization?” and “Do you
saying, “Would it be better if we were alone for this have any questions?” This last question indicates that
interview?” Eliminate excess noise by turning off elec- the interview is coming to an end. A brief summary
tronics. Be certain the patient is comfortable, draw up statement, ending with “I think I have the information
a chair to within 3 to 4 feet, and sit down facing the I need,” closes the interview. Thank the patient for sup-
patient (Figure 8-3). Chapter 5 contains more informa- plying the information collected before finishing. An
tion about the interview. example of the nursing admission history form is
found in Chapter 5.
Elder Care Points

When taking a lengthy history from an elderly patient, it may be
necessary to redirect the interaction frequently if the patient
focuses too long on one illness or hospitalization.

THE NURSE-PATIENT RELATIONSHIP

The nurse-patient relationship focuses on the patient,
has goals, and is defined by specific boundaries. The
relationship takes place in the health care setting, and
boundaries are defined by the patient’s problems, the
help needed, and the nurse’s professional role. When
FIGURE 8-3 Interviewing the patient. the patient is discharged, the relationship ends.
Good communication skills establish a therapeutic for less pain, peace, a pleasant moment, and a good
relationship between you and the patient that assists in laugh. A patient with cancer can hope for a positive
the healing process. In this relationship, you are in a prognosis, a healing outcome from surgery or therapy, or
helping role rather than a social role. Interaction emotional growth from the illness experience. The nurse
between you and the patient should build trust. Without should help the patient establish realistic hopes, but even
trust, the patient will discount much of what you say. unrealistic hopes should not be totally dismissed. Hope
A social relationship differs from a therapeutic one is what helps a patient cope in a difficult situation.
in that the focus is on both participants and the usual
goal is to meet one’s own needs. The social relation- Application of the Nursing Process
ship is established for mutual enjoyment, with consid- Assess the patient’s language ability during the first
erable sharing of experiences, life events, and thoughts. encounter. Consider the following questions when
Characteristics in the nurse that facilitate a therapeu- gathering data about the patient’s communication
tic nurse-patient relationship include effective commu- needs:
nication skills, empathy (ability to understand the • Is English spoken and understood, or is a transla-
situation from another’s perspective), a desire to help, tor needed?
honesty, a nonjudgmental attitude, genuineness, accep- • Is the vocabulary level equivalent to that of the
tance, and respect. Confidentiality, or keeping informa- average person of this age, or will it be necessary
tion private, must be maintained for trust to endure. to simplify language?
• Does the patient have a neurologic impairment
EMPATHY that causes problems with the comprehension of
Empathy is the ability to place oneself in another’s oral or written communication or with the ability
position. It involves being able to see situations from to hear or speak?
another person’s perspective and perceive them as that • What cultural factors affect how this patient
person does. If empathy is present, the other person’s interacts verbally?
feeling is understood. Empathy is different from sym- • How much personal space does the person need?
pathy. With sympathy, concern and perhaps sorrow • If the person is unable to speak but can commu-
are felt, indicating that the person is experiencing nicate in writing, what provisions should be
something difficult. Warmth, a nonjudgmental atti- made to accommodate this?
tude, and a focus on the patient’s feelings are present Patients who have problems with communication
when empathy is expressed. Be careful about saying “I are given the nursing diagnosis Impaired verbal com-
know how you feel” or “I understand what you are munication. If the problem is related to difficulty with
going through” because no one can really know or feel hearing, use the nursing diagnosis Disturbed sensory
what someone else is experiencing. State an interpreta- perception.
tion of the patient’s feeling and then seek validation In addition to writing individual expected out-
that the interpretation is accurate. comes, you must plan appropriate amounts of time
with the patient for a communication interaction. An
Think Critically assessment interview should not take more than one-
half hour. If the patient has communication impair-
Why is empathy important in the nurse-patient relationship?
Discuss incidents where you (or someone you observed) had ment, varying amounts of time will be needed for each
trouble feeling empathy for a patient. What were the outcomes? interaction. When a patient does not speak English,
What could have been done to alter the situation? plan ahead and locate an interpreter before beginning
an interaction with the patient.

BECOMING NONJUDGMENTAL
NURSE-PATIENT COMMUNICATION
Becoming nonjudgmental takes considerable practice
and discipline and is directly related to the degree of Trust and understanding are the keys to effective nurse-
empathy a person is capable of generating. It is far eas- patient communication. When the nurse possesses
ier to accept people as they are if you can truly see knowledge, skills, and attitudes (KSAs) related to patient-
things from their perspective. Patients come from all centered care, successful nurse-patient communication
kinds of backgrounds and have many different sets of can be achieved. (See Table E8-1 on the Evolve website.)
values. To be nonjudgmental, you must look at the
patient in reference to her values rather than your own. COMMUNICATING WITH THE
HEARING-IMPAIRED PATIENT
MAINTAINING HOPE When a patient has a hearing impairment, determine
Maintaining hope is an important part of the nurse- how to interact with the patient to promote the best
patient relationship. There is always hope, even if the level of communication. If the patient has hearing aids,
direction of hope changes. The dying patient can hope see that they are used, that the batteries are functioning,
and that the device is turned on. A hearing aid does not
guarantee that the individual will hear perfectly. The
following techniques promote comprehension for a
hearing-impaired person:
• Get the person’s attention, making certain the
person is aware that verbalization is going to take
place. If the person is seated, sit down.
• Face the person directly. Speak slowly and dis-
tinctly. Do not cover your mouth, chew gum, or
have food in your mouth when speaking.
• Do not shout, since this can distort speech.
• Maintain voice pitch at mid-range, neither low
nor high.
• Maintain a distance for speaking to a hearing-
impaired person of 21⁄2 to 4 feet. FIGURE 8-4 Communicating with an aphasic patient.
• Never speak directly into the person’s ear. This
can distort the message and hide all visual cues.
• Be aware of nonverbal communication. Box 8-1 Communicating with the Aphasic Person
• Use short, simple sentences. Try to limit each sen- • Make the environment as relaxed and quiet as possible.
tence to one subject and one verb. • Assume the patient can understand what is heard unless
• If the patient does not appear to understand or deafness has been diagnosed.
responds inappropriately, rephrase the statement. • Speak to the patient as an adult; do not act as if the
• Give the person time to respond to questions. patient is mentally incompetent.
• Ask for rephrasing to make certain the patient • Talk to the patient; do not talk to someone else in the
has understood important information. room about the patient.
• Face the patient, establish eye contact, and speak slowly
COMMUNICATING WITH AN APHASIC PATIENT and distinctly without dropping the voice level at the end
of sentences; do not shout.
The patient with aphasia (difficulty expressing or • Give directions with short phrases and simple terms; use
understanding language) will require specialized nurs- gestures to enhance the words.
ing interventions. Recruit the assistance of a speech • Phrase questions so that they can be answered with a
therapist to determine methods to facilitate communi- “yes” or “no,” and look for nonverbal behavior that agrees
cation for these patients. A white erasable board is with the patient’s answer.
handy for aphasic patients who can write (Figure 8-4). • Give the person time to respond to questions; process-
Some techniques can be helpful when communicating may be slower than usual.
ing with a patient who has aphasia as a result of neuro- • Ask only one question at a time; be patient and wait for
logic damage from a stroke or head injury. The use of an answer.
appropriate nonverbal gestures sometimes helps. • If you need to repeat something, use the same words the
second time. If there is still difficulty, phrase what was
Guidelines presented in Box 8-1 can assist you in com-
said differently.
municating more effectively with the aphasic patient. • Use body language to enhance the message.
(See Nursing Care Plan E8-1 on the Evolve website.) • Allow one person to speak at a time.
• Be patient.
COMMUNICATING WITH THE ELDERLY
The elderly vary greatly in their communication abili-
ties, interests, and capabilities. Healthy older adults Wait for an answer to one question before asking
sometimes require more time to think and formulate a another. Introduce one subject at a time in the conver-
response. Other older adults may have hearing, sensation, and give only one instruction in any one sen-
sory, or motor impairments that interfere with commu- tence. It is important for all members of the health care
nication. Be certain you have the person’s attention team to communicate in a consistent manner with
before beginning an interaction. Eliminate outside dis- elderly patients.
tractions. Introduce one idea at a time, and do not rush
the person, as this may cause confusion. Assignment Considerations
It is especially important to obtain feedback from an Sharing Communication Tips
older adult that the message has been clearly under- Nursing assistants often provide much of the basic care related
stood. If people have difficulty comprehending, they to activities of daily living (ADLs) for elderly people. Share your
may just nod their head, pretending to understand, for knowledge about how to communicate with elderly patients
fear of appearing forgetful. Many are embarrassed and ask the assistants for their input. Also ask them to share
about their hearing deficiency. their communication success stories.

COMMUNICATING WITH CHILDREN

When communicating with children, consider the influ-
ence of development on language and thought pro-
cesses. Young children are very responsive to nonverbal
messages. A young child may become frightened by
sudden movements or gestures. Approach children at
their eye level and use a calm, quiet, friendly voice.
When interacting with an infant, keep the mother
within the baby’s view. With a toddler or a preschooler,
focus on the child’s needs and concerns. Use simple,
short sentences and concrete explanations with famil-
iar words.
For the school-age child, give simple explanations
and demonstrate how equipment works. Allow the FIGURE 8-5 Communicating with the assistance of an interpreter.
child to handle the equipment if possible. Listen care-
fully to the child’s fears or concerns.
An adolescent needs time to talk. Use active listen-
ing, avoid interrupting, and show acceptance. Try not
to give advice, and avoid embarrassing questions if at
all possible.
Above all, with any child, be honest and tell the
child what to expect.
COMMUNICATING WITH PEOPLE FROM

OTHER CULTURES
Determine whether the person speaks and understands
English. If not, follow your facility’s guidelines for
obtaining an interpreter. Be accepting; do not show
impatience with someone’s lack of ability to speak Eng- FIGURE 8-6 Communication board on a nursing unit.
lish. Facilities that accept federal funds (e.g., Medicaid)
are legally required to provide language access to all to dissatisfaction with care. Most communities have
patients. Most health care agencies have a list of inter- classes for students who wish to improve their English.
preters that can be called for assistance (Figure 8-5).
Follow the patient’s lead about the use of eye con-
COMMUNICATION WITHIN THE HEALTH CARE TEAM
tact and distance. If the patient is not comfortable mak-
ing eye contact, respect this cultural difference. Watch Communication within the health care team occurs
how much distance is maintained between the patient through writing and reading nurses’ notes; physicians’
and other people when they interact. orders; the dietitian’s notes; and notes and orders of
the respiratory, physical, speech, and occupational
Cultural Considerations therapists, as well as listening to and giving a shift

report (a verbal communication on the details of a
Assisting Elders from Other Cultures
patient’s condition and treatment). Completing forms
In some cultures, older adults are not accustomed to taking for the laboratory, radiology, and other departments is
instruction from a young person. It may be necessary to enlist
another method of communication. Entering informa-
the aid of an adult family member who will learn the essentials
tion on the computer is an essential tool for communi-
of self-care for the patient, and then have that person perform
the patient teaching. Provide printed materials and be available cation among hospital departments. Communication
to demonstrate or answer questions. boards can be helpful for reminding team members

about patients at risk for falls or other problems to
If you are from your community’s nondominant watch for (Figure 8-6). Clear communication is neces-
culture and your primary language is not English, it is sary when consulting with physicians about orders
important to work on your English language skills and and when delegating tasks to ancillary workers.
correct pronunciation. Your patients depend on good
communication with you. If you cannot communicate END-OF-SHIFT REPORT
well in English, you may miss important signs and Many different formats are used to give a report. Some-
symptoms of a change in a patient’s condition. When a times the report is given as the nurses from the off-going
patient is unable to communicate well with the nurse, and oncoming shifts walk from room to room together;
it adds further stress to the patient’s situation and leads known as walking rounds. If the report is recorded on
an audiotape or if computerized sheets are used, there Computer-printed information sheets are available
must be an opportunity to ask and respond to ques- at the beginning of the shift for the oncoming nurse in
tions. Whatever format is used, the same essential most hospitals. This sheet can be taken and used as a
information is necessary for each patient. Get in the work organization sheet. If notes are added to the sheet
habit of organizing the report in the same way each during the shift, all the information needed for the
day. A full report on each patient should take about 1 to report at the end of the shift should be readily at hand.
3 minutes. Give only essential information. It takes
practice to give a logical, organized, concise report on TELEPHONING PHYSICIANS
a group of patients. Practicing at home with an audio Physicians must be telephoned from time to time.
recorder can help you gain confidence and present Orders may be unclear, the patient’s condition may
information more concisely. Box 8-2 presents the infor- change, the patient may have a particular request, or
mation usually given in an end-of-shift report. Styles you may need further information about the patient.
of reporting include ISBAR-R (Introduction, Situation, If a physician is called regarding a change in a
Background, Assessment, Recommendation, and Read- patient’s condition or in any situation in which new
back) and SBAR-Q (Questions) formats. If the initial orders are anticipated, certain steps should be followed.
information is handed out on a computer printout, it Have current data on the patient at hand, including
need not be repeated. The room number and patient’s data from the last vital signs assessment, pertinent lab-
name are sufficient as a starting point after introducing oratory data, information on urinary output, and medi-
yourself. See the Evolve website for an ISBAR-R tem- cations received. Keep the chart handy, have a pen
plate you can use for handoff reporting. ready, and anticipate the information that the physician
might need to make a decision. Know what allergies
the patient has. Perform a quick assessment before call-
Safety Alert ing, and prepare a concise statement of the problem or
concern. Document the call, and note the health care
ISBAR-R
provider’s statement that the order is correct as read.
In accordance with the National Patient Safety Goals and the
QSEN program, an end-of-shift report should be conducted in
a standardized manner to reduce the risk of patient injuries and Safety Alert
errors during hand-off communication. The ISBAR-R format Taking Telephone Orders
gives caregivers the opportunity to ask and respond to ques-
tions concerning patient care. This format is borrowed from To apply the ISBAR-R format to a telephone order from a physi-
military communication models and has been successfully cian, you should introduce yourself (including the hospital unit),
used in some health care settings. verify the patient’s name and condition, listen to the order, write

down the order, and then read it back to the doctor (Box 8-3).

The student nurse should have an instructor or

Box 8-2 Information Included in End-of-Shift Report another registered nurse standing by to speak with the
• Room number, bed designation; patient name, age, and physician and take the order again, including readback,
sex; date of admission; medical diagnoses; and name of because students cannot legally take telephone orders.
primary physician. (If a computer census sheet is used
ASSIGNMENT CONSIDERATIONS
that contains some of this information, then only the

room number and name and any missing data are given.) AND DELEGATING
• Tests and treatments or therapies performed in the past You must communicate well in order to assign tasks and
24 hours with patient response (e.g., computed tomog- delegate (authorize another person to do something) to
raphy [CT] scans, surgery, procedures); intake and out-
others effectively. Give clear, concise messages and lis-
put for past shift.
• Significant changes in patient condition.
ten carefully to feedback. Include the desired results and
• Scheduled tests; consults or surgery; current intravenous the time constraints for completion of the task. It is better
solution, flow rate, and amount remaining; next solution to say, “Let me know if Mrs. Hope’s noon temperature is
to be hung; oxygen flow rate; equipment in use and cur- above 101.2° F” than to say, “Let me know if Mrs. Hope’s
rent settings (e.g., gastric suction on low). temperature is high.” Ask the person to whom you are
• Current problems (e.g., dehydration, severe pain, anxiety, assigning a task if there are any questions about what is
depression, insufficient rest, or abnormal laboratory val- to be done, and ask for a summary of what is understood
ues or test results); amount of assistance with activities of about the task to be done. Although a task may be dele-
daily living (ADLs) needed. gated, the ultimate responsibility will remain with you.
• Scheduled treatments, PRN (as needed) medications
given, times given, patient response. COMPUTER COMMUNICATION
• Concerns, need for order changes, teaching, pertinent
family dynamics, and emotional status.
The computer is used to transmit requests for laboratory,
dietary, radiology, physical therapy, respiratory therapy,
and other services. The physician enters medication access information using your password, and never share your
orders into the computer, and the orders are communi- password with others. If your facility uses e-mail to communi-
cated to the nurse on a patient medication administra- cate about patient care, you will likely receive training to pre-
tion record. Supplies for patient care are ordered on vent HIPAA violations (see Chapter 3).

the computer, and patient care plans are updated using

the keyboard or a touch screen (Figure 8-7). Many hospitals and home care agencies are convert-
ing to computer charting. In some agencies a hand-
Box 8-3 Example of ISBAR-R Communication held computer is used to note medications given, input
(put in information) vital signs, chart assessment data,
I: Dr. Savoy, this is Nurse Lopez at ABC Extended Care Facility. and record the nurse’s observations. Computer skills
I’m calling in regard to Mr. Tanglewood in room C12. are essential for today’s nurse.
S: Mr. Tanglewood is an 85-year-old man with Alzheimer
disease. He tripped in the bathroom and bumped his
head on the toilet about 30 minutes ago. One of the COMMUNICATION IN THE HOME AND COMMUNITY
nursing assistants saw him trip, and there was no loss of
consciousness at any time. Nurses who work in home care often have both a pro-
B: He is normally alert and oriented to person, and he fessional and a social relationship with their patients
routinely ambulates independently. and families. Often, the nurse is the only person whom
A: His blood pressure is currently 140/83, pulse 75, the patient sees on the day of a visit. Because of the
respirations 16/min. He has a 3-cm laceration and social aspects of the visit, it is essential to state when
hematoma just superior to his left eyebrow. The bleed- instructions are about to be given so that active listen-
ing was readily controlled with direct pressure. We have ing can occur.
applied an ice pack and pressure bandage over the
wound. He is alert, and his speech is clear and appropri-
ate to his baseline. He denies any pain, and he does not Home Care Considerations
seem to have tenderness or bruising except on his fore-
Tips for Efficient Interviewing
head, but he did extend his right hand to break his fall.
R: Could I get an order to have him transported to the Before the initial home visit, ask the home care patient or family
emergency department for additional evaluation and to list all medications the patient is taking, including over-the-
treatment? And do you have any additional orders for counter medicines and herbal preparations, and to have the
Mr. Tanglewood? vials and bottles all in one place. Ask that a list of the patient’s
R: Thank you, Dr. Savoy. Let me repeat that order. Mr. Tan- physicians with phone numbers be ready for you, plus the
glewood will be transported to the emergency depart- dates of any recent hospitalization or surgery. This will save you
ment by ambulance. After the evaluation he will be sent time when doing the interview, and you can take the lists with
to radiology for x-ray examination of his right hand. you for the later completion of your paperwork. Leave written
step-by-step instructions with the patient whenever possible.
The primary nurse will often call between visits to see how
treatment is progressing and to assess for any problems.

Safety Alert
Telephone Communication in Home Care Settings
In accordance with The Joint Commission’s National Patient

Safety Goals, it would be inappropriate for a physician to leave
orders for a home care patient on a voice mail message or to
ask the family to convey the orders to the nurse. Likewise, a
nurse should not leave instructions for a nursing assistant on a
voice mail. Exchange of phone information between members
of the health care team should follow the ISBAR-R format.

FIGURE 8-7 Communicating by computer. Office and clinic nurses often assess patients who
call in to see whether they have an urgent need for
medical attention. Such assessment requires good
Legal & Ethical Considerations
communication to obtain the data needed to make
Computer Usage and Safeguarding Patient Information such a decision (Figure 8-8). The office nurse gives tele-
Computerized patient information requires extra vigilance to phone instructions to patients on how to treat minor
safeguard confidentiality. When you use the computer at the illnesses or injuries. It is important in these situations
health care facility, never leave a computer screen open when to obtain feedback so that there is no doubt that the
you are finished. Always log out so that someone else cannot patient understands the instructions.
FIGURE 8-8 The nurse instructs a clinic patient over the telephone.
Key Points • Handoff report should include patient’s name, age, and
changes in condition; current concerns; treatments; and
• Communication is a continual, circular process and response to therapies, and should use the format
occurs in two ways: verbal and nonverbal. ISBAR-R.
• Culture, experience, emotions, attitude, mood, and • When taking telephone orders, introduce yourself and
self-concept all contribute to the way people verify the patient, listen, write, and read back what you
communicate. have written.
• An active listener maintains eye contact without staring, • Protect passwords and log off when using the computer.
gives the patient full attention, and makes a conscious
effort to block out other sounds and distractions.
• Silence and therapeutic touch can be effective forms of Additional Learning Resources
communication.
• Asking open-ended questions, restating, clarifying, using SG Go to your Study Guide for additional learning activities to help you
general leads, offering of self, encouraging elaboration, master this chapter content.
giving information, looking at alternatives, and summariz-
ing are all therapeutic communication techniques. Go to your Evolve website (http://evolve.elsevier.com/deWit/
• Changing the subject, offering false reassurance, giving fundamental) for the following FREE learning resources:
advice, making defensive comments, asking probing • Animations
questions, using clichés, and inattentive listening are • Answer Guidelines for Think Critically boxes and Critical Thinking
blocks to good communication. Questions and Activities
• A therapeutic relationship focuses on the patient; helping • Answers and Rationales for Review Questions for the NCLEX®
the patient maintain hope is important. Examination
• Empathy, a desire to help, honesty, a nonjudgmental • Glossary with pronunciations in English and Spanish
attitude, genuineness, acceptance, and respect for the • Interactive Review Questions for the NCLEX® Examination and
individual also facilitate a therapeutic nurse-patient more!
relationship.
• Special communication techniques are needed for the Online Resources
patient experiencing aphasia, for patients with a hearing • Review the case studies of two children who died as a result of medical
impairment, and for children. errors. What can we learn about patient communication and empathy
• Be accepting and do not show impatience if a patient from these tragic events? (Note: although QSEN asks viewers to set up
does not speak English; look for cultural cues regarding an account, the account is free to set up and allows access to these very
eye contact and distance between speaker and listener. moving and personal stories.)
1. The Josie King Story, www.qsen.org/video/josieking 4. Give the person time to respond to questions.
2. The Lewis Blackman Story, www.qsen.org/video/blackman 5. Explain procedures to the family member instead of
• Improving Patient-Provider Communication (Joint Commission Video): the patient.
www.jointcommission.org/multimedia/improving-patient-provider- 6. Give directions with short phrases and simple terms.
communication---part-1-of-4/
6. The patient is about to undergo surgery. Which
statement is an example of false reassurance?
Review Questions for the NCLEX® Examination 1. “Your surgery will take about 51⁄2 hours.”
Choose the best answer for each question. 2. “You’ll come through this procedure just fine.”
3. “Your family will be allowed to see you as soon as
1. The nurse is using therapeutic communication to you are awake.”
establish rapport. The nurse says, “How are you feeling 4. “This surgeon has done many of these operations.”
this morning?” Which nonverbal behavior is congruent
with the nurse’s verbal question? 7. Which element characterizes a therapeutic relationship?
1. Looks at patient; stands with a relaxed body position 1. Focus is on the patient’s needs, and there are
2. Nods head up and down; arms folded across chest specific goals.
3. Smiles at patient and makes the bed while patient 2. The patient and the nurse get satisfaction from the
answers relationship.
4. Adjusts IV and evaluates equipment and 3. The patient and the nurse equally exchange
environment information.
4. The relationship is terminated if needs are not being
2. A patient expresses serious concerns about the satisfied.
outcomes of a scheduled surgical procedure. Which
response indicates that the nurse is using active 8. Which observation might indicate the staff could benefit
listening while the patient is speaking? from an in-service on the topic of patient-centered care
KSAs?
1. Nurse tells the patient not to worry about the
surgery. 1. Nurses are seen consistently demonstrating
2. Nurse asks the patient to take her medication before principles of effective communication.
continuing. 2. Nurses are allowing family members to bring in
3. Nurse asks the patient why she is afraid of the home remedies “from the old country” after
surgery. obtaining permission from the physician.
4. Nurse nods his head. 3. The unit implements a 24-hour visitation policy.
4. The staff complain about admitting patients from a
3. What is a correct beginning for an ISBAR-R certain geographic region of the world because “they
communication with a physician? are always so loud.”
1. “Your patient, Mr. Leo, is agitated and combative.”
9. A way to promote trust with a patient is to:
2. “Dr. Williams, this is Patricia, the nurse caring for
your patient, Mr. Leo.” 1. allow family members to visit whenever they want.
3. “Mr. Leo has demonstrated escalating inappropriate 2. assure the patient that her physician is excellent.
behavior ever since his dose of Lithium was 3. follow through when you say you will do something.
reduced.” 4. talk with her at length, about her life, likes, and
4. “I need you to come and evaluate your patient, dislikes.
Mr. Leo.”
10. A nurse is assigning a task to the nursing assistant.
4. A patient says, “I don’t know what to do about the Which is the best example of how to communicate the
problem.” The most therapeutic response would be: task to the assistant?
1. “You should define the problem and make a plan.” 1. “Please do all the vital signs for my patients, and pay
2. “What options are you considering?” special attention to Mrs. Hondo and Mr. Takeda.”
3. “That’s not a big problem, you can handle that.” 2. “Please report any abnormal vital signs throughout
4. “What does your doctor say you should do?” the day, and keep an eye on Mrs. Hondo and Mr.
Takeda.”
5. The patient is aphasic. Which communication strategy 3. “Please check Mrs. Hondo’s and Mr. Takeda’s blood
would be appropriate in working with this patient? pressure and pulse as ordered by the physician. Call
(Select all that apply.) me if you have problems.”
1. Lean forward and say “Go on….” 4. “Please do vital signs at 8 a.m. on Mrs. Hondo and
2. Face the patient, establish eye contact, and speak Mr. Takeda, and if the pulse is more than 85 per
slowly. minute, let me know.”
3. Use gestures to enhance the words.
Critical Thinking Activities Scenario B

Consider your own communication style. What three
Read each clinical scenario and discuss the questions with factors do you think have had the greatest influence on the
your classmates. way you communicate?
Scenario A Scenario C
You are working with a patient who is quiet and withdrawn. Develop your own checklist for giving handoff report. Why
When you walk into her room, she appears tearful and is it important for the oncoming nurse to have an opportu-
upset, but she tells you that nothing is wrong. How would nity to ask questions?
deal with this situation?
chapter
Patient Teaching and Health Promotion 9

Objectives
Theory 7. Name three things that must be included in the documen-
1. Discuss the purposes of patient teaching. tation of patient teaching.
2. Use patient teaching to promote the national goals of 8. Describe ways for teaching to be continued after hospital
health promotion and disease prevention as listed in discharge.
Healthy People 2020 and the Health Goals for Canada. Clinical Practice
3. Describe three ways in which people learn, and correlate 1. Assess an assigned patient’s learning needs.
the importance of these types of learning to teaching. 2. Develop a teaching plan based on the patient’s learning
4. List and differentiate between conditions and factors that needs.
can affect learning. 3. Implement the teaching plan at a prearranged time.
5. Identify adjustments to the teaching plan needed for teach- 4. Evaluate the effectiveness of the teaching and the plan.
ing the very young patient or the elderly patient.
6. Discuss types of resources available to assist in patient
teaching.
Key Terms
affective domain (dōw-MĀN, p. 116) kinesthetic learning (kĭn-ĕs-THĔT-ĭc, p. 116)
auditory learning (ăw-dĭ-TŌR-ē, p. 116) psychomotor domain (sī-kō-MŌ-tŏr, p. 116)
behavioral objectives (bē-HĀV-yōr-ăl, p. 119) return demonstration (p. 120)
cognitive domain (KŎG-nĭ-tĭv, p. 116) visual learning (p. 116)
feedback (p. 120)
preventable disease, disability, injury, and premature

PURPOSES OF PATIENT TEACHING
death.” Objectives speak to promoting healthy
The ultimate goal of patient teaching is the prevention behaviors, protecting health, ensuring access to high-
of illness, promotion of wellness, and restoration of quality health care, and strengthening community
health. Nurses teach patients about their disease or health promotion programs. Canadian goals are very
disorder, surgery, and self-care (Box 9-1). Preoperative holistic.
teaching covers the various phases of the surgery, what Discharge planning requires looking ahead to
will be experienced, what can be expected, and the meet the patient’s ongoing needs at home. It is a pro-
exercises to be done afterward. With same-day surgery cess that begins at the time of admission. This
and hospital stays being so short, patient education includes assessing for special needs, learning to iden-
has become an even higher priority. Before discharge, tify appropriate teaching moments, and providing
the patient must be taught how to care for himself at learning opportunities that are brief and focused on
home. This requires collaboration on the teaching plan preparing the patient for self-care. A teaching
among the various health professionals involved in the moment occurs when the patient is at an optimal
care, as well as communication with the family and level of readiness to learn and apply a particular
home care nurse, if any. piece of information. Take cues from the patient’s
Patient teaching contributes to achievement of the questions, or try to stimulate interest in what he
goals of Healthy People 2020, a program of the U.S. needs to know. Saying, “You’ll want to know things
Department of Health and Human Services, and the you can do to lower your risk of another heart attack”
Health Goals for Canada. An objective of Healthy People tends to stimulate interest in the recovering myocar-
2020 is to “attain high quality, longer lives free of dial infarction patient.
115
Box 9-1 Topics for Patient Teaching Think Critically

• The disease process Which of the three routes of learning usually works best for
• Preoperative and postoperative care you? How have you seen a child learn? An older adult?

• Diagnostic tests and procedures
• Information needed for self-care and restoration
During the teaching sessions, listen to how the
• Diet
• Exercise
patient makes responses because the language used
• Medication purpose, schedule, and special consider- may give clues to the person’s best learning mode.
ations Learning can also be categorized by domains. In the
• Medication side effects cognitive domain the learner takes in and processes
• Symptoms to report to health care provider information by listening to or reading the material. In
• Skills such as asepsis, dressing change, splint or brace the affective domain the material is presented in a way
attachment, injections, IV administration at home, use of that appeals to the learner’s beliefs, feelings, and val-
mechanical or other aids ues. For example, people must value cleanliness before
• Prosthesis care you can teach them to wash their hands frequently. In
• Working with a physical therapist the psychomotor domain the learner processes the
• Working with a speech therapist
information by performing an action or carrying out a
• Working with an occupational therapist
• Prevention of illness and health promotion
task. All three domains are important to the patient’s
• Stress reduction and relaxation techniques translation of the learning to desired behaviors.
• Proper cough technique
• Smoking cessation ASSESSMENT OF LEARNING NEEDS
• Immunizations
• First aid To prepare a teaching plan, you must first know what
• Hygiene the patient needs to learn. What does the person need
• Safety (home, car, workplace, etc.) to know about the disease or condition, diet, activity,
• Prenatal care medications, wound care, treatments, or self-care at
• Infant and child care home? This information establishes the learning needs.
• Parenting
• Nutrition
• Exercise benefits Focused Assessment
• Beneficial screenings (blood pressure, vision, cholesterol, Assessment for Teaching and Learning
mammography, prostate-specific antigen, blood glucose,
Assess the following:
skin for cancer, colonoscopy, etc.)
• Any barriers to learning
• Disaster preparedness
• Ability to learn
Key: IV, Intravenous. • Cultural factors to be considered
• Language level and literacy; need for interpreter
• Patient’s health beliefs
Think Critically • Emotional and physical readiness to learn
• Patient’s learning goals
Can you list three general teaching topics that might be appro- • Patient’s best learning style
priate for most patients under your care?
• Family support and availability

• Concerns about learning skills
• Concerns about care after discharge
MODES OF LEARNING • Materials available for teaching
• Location for teaching with appropriate environment
Research has shown that people learn in three ways:
• Times when teaching could take place
(1) visually, through what they see (visual learning); (2)
aurally, through what they hear (auditory learning); and

(3) kinesthetically, by actually performing a task or Patients may require far more complex teaching
handling items (kinesthetic learning). Although most than can be accomplished in the short time before
people can learn by any of these routes, one route is discharge. In such cases the basic survival skills are
usually dominant. For example, if a person is primar- taught first, and after discharge the advanced skills
ily a visual learner, telling him everything and not are taught in group or private sessions. Often, a home
using any written materials or visual examples will health nurse continues with the teaching plan. Make
make learning much more difficult. Many people do a list of the learning needs and then prioritize them
not know how they learn best. It is important to use a so that you can concentrate first on teaching the
variety of teaching techniques so that the patient both essential knowledge needed for safe care at home.
sees and hears the information and performs the action Place the identified learning needs on the patient’s
being taught. care plan.
Patient Teaching and Health Promotion CHAPTER 9 117
Confidence and Ability

Think Critically
Often patients express a lack of self-confidence, saying,
How would you assess the patient’s current understanding to “I’ll never be able to do that.” In such instances you
determine where he has knowledge deficits related to his must explore these feelings, being careful to enhance
health or self-care?
rather than harm the patient’s self-esteem. Praise and
encouragement go much further than admonishment
FACTORS AFFECTING LEARNING in promoting needed learning. Teaching may need to
Before beginning to teach, you must assess for factors be broken down into small steps.
that might interfere with the patient’s ability to learn.
Conditions that can affect the learning process include Communication
poor vision or hearing, impaired motor function, illit- Teaching the Patient Who Lacks Self-Confidence
eracy, and impaired cognition. Age may interfere with
the strength or dexterity for performing certain tasks. Mrs. Dunn, age 72, is to be discharged tomorrow. She has
a wound on her left thigh that needs to be cleaned and
Consider all barriers to learning before beginning to
dressed daily after discharge.
teach. Physical, occupational, or speech therapists can Nurse: “Mrs. Dunn, I’ve brought the supplies we need to do
be helpful in helping the patient overcome these types your dressing change.”
of problems so teaching can begin. Mrs. Dunn: “Oh, I don’t think I can do it myself; it seems so
Situational factors that interfere with learning include complicated.”
pain, nausea, fatigue, a sense of being overwhelmed by Nurse: “We’ll work on it a step at a time. By the time you go
all that is happening, and multiple interruptions. home tomorrow, you will feel much better about it.”
Mrs. Dunn: “Well, I’m willing to try. I do want to go home.”
Cultural Values and Expectations Nurse: “The first step is easy, we just wash our hands.”
The patient’s cultural values and personal expecta- Mrs. Dunn: “Oh, good, I already know how to do that!”
tions regarding treatment and recovery may differ Nurse: “Now, I use gloves here in the hospital, but you won’t
need to do that.”
from those of the nurse and other health care provid-
Mrs. Dunn: “I’m glad. Gloves make me so clumsy.”
ers. This can interfere with the patient’s ability to coop- Nurse: “Are you right-handed? OK, remove the old dressing by
erate and learn needed skills for self-care. gently holding the skin smooth with your left hand while pull-
ing the tape up with your right hand.”
Cultural Considerations Mrs. Dunn: “That was easy.”
Acceptance of Teaching Nurse: “Good. Watch me open this package of gauze squares.
Open the top and peel back the sides. Stop when you get to
While planning teaching for male patients of other cultures, find the bottom seam. Can you open that one for me?”
out if the man will be receptive to your teaching. Traditional The patient picks up the package. She fumbles at first,
older Japanese men may not heed what a younger female is then manages to grasp the edges and pull them apart as
trying to teach. This may apply in other cultures as well. Inter- instructed. The nurse does not rush her.
action with the family or with the patient himself can provide the Nurse: “Perfect. Now place it on the table with the paper side
needed information. down, like this.”

The patient places her pack as the nurse has shown her.
It is necessary to work within the patient’s values Nurse: “Now open the bottle of sterile water like this.”
and cultural system. The patient may wish to use herb The nurse opens a bottle and sets the cap down on
poultices on a wound rather than the medication the the table upside down.
physician prescribes. Often a compromise can be Nurse: “By laying the cap down this way, the open side stays
worked out, such as alternating the poultice with the clean and will not contaminate the bottle when I put it back
medication prescribed (as long as the poultice is not on. Now, you do it.”
harmful). As an aid to healing, patients may practice The patient picks up the bottle and twists it open, laying
religious rituals with which the nurse is unfamiliar. In the cap on the table like the nurse did.
hospitals on American Indian reservations, it is com- Nurse: “You’re a fast learner, Mrs. Dunn. Now, pour a little on
the gauze squares like this.”
mon to see a physician and a tribal shaman working
The patient watches, then pours some water in the
side by side, honoring the strong belief that physical
middle of her gauze squares.
healing must be accompanied by spiritual healing. Nurse: “Now pick up one of the gauze squares and clean the
Such practices rarely conflict with medical treatment wound just like the nurses have been doing it.”
and may greatly benefit the patient. Mrs. Dunn: “I’ll try, but this is the part that always hurts.”
Nurse: “I know, but it usually hurts less when you do it yourself.
And if it isn’t cleaned out well, it won’t heal. You can take
Think Critically
some acetaminophen about an hour before you change the
Can you think of a situation in which a patient’s culture or value dressing. That will help. I’ll do the first square, then you do
system might prevent his cooperation with learning self-care the second, OK?”
aspects of his treatment plan? The nurse swabs out the wound gently.

Continued
Nurse: “Now you try it.” area is also noted. The teacher may be the nurse, physi-
The patient picks up the gauze, squeezes out the excess cal or occupational therapist, dietitian, speech therapist,
water, and dabs a couple of times at the wound. or respiratory therapist. The nurse is responsible for
Mrs. Dunn: “Like that?” overseeing the plan specifics. Even when another per-
Nurse: “Yes, that’s the idea. See if you can go over the wound
son is doing the teaching, the nurse reinforces it. Con-
a little more slowly from top to bottom with a new gauze
sistency in teaching is important if the patient is to
square. It’s important to use a clean one each time you go
back over the area.” master and retain the new information.
Mrs. Dunn: “OK. Is this better?” Play techniques can be successful when teaching
Mrs. Dunn cleans the area a little more thoroughly. younger children. The use of dolls and play equipment
Nurse: “Yes. I’ll give you some acetaminophen before we meet is appropriate and helpful. Teaching must be done in
this afternoon and see if that makes it easier for you.” short segments to allow for the child’s limited atten-
The nurse finishes cleaning the wound. tion span. Language must be tailored to the child’s
Nurse: “Now Mrs. Dunn, squeeze a bit of this antiseptic oint- level of understanding. Children interpret language
ment into the wound.” literally, so avoid idioms because they can be easily
Mrs. Dunn: “How much do I use?” misunderstood.
Nurse: “Just a line down the center. It will spread out when the
When teaching the elderly, the pace is slowed to
dressing is applied.”
allow more time for processing the information.
The patient squeezes the ointment into the wound.
Nurse: “That’s right. Now, for the dressing you want to use a
nonadhering pad as the first layer. Cut the one marked ‘Telfa’ Patient Teaching
in half. You can cut right through the closed package, and
the second half will be in a wrapper waiting for next time.” Special Considerations When Teaching the Elderly
Mrs. Dunn: “Oh, good. I hate to waste things.” When preparing to teach an elderly patient, consider the
Mrs. Dunn cuts the Telfa pad in half. following:
Nurse: “Now, let’s get the tape ready before you take the • Provide good lighting; a light source coming over the shoul-
wrapper off the Telfa. We will be putting gauze over the Telfa der of the patient is excellent.
and you will need to tape all the way around the edges. If you • Provide written materials to enhance what is taught.
tear the four pieces of tape and gently stick one end to the • Printed materials should be in large type and are visualized
table edge, they will be easy to get when you’re ready for best when they are in black type on white nonglare paper.
them.” • Be certain the patient is wearing glasses, if needed, and that
Mrs. Dunn: “OK. This is what I do when I’m wrapping pack- the lenses are clean.
ages.” • If the patient wears a hearing aid, be certain it is turned on
Nurse: “Then you are a tape pro, Mrs. Dunn. Now, lay the Telfa and adjusted.
dressing on the wound and gently press it down. That • Use short sentences and speak slowly; pause frequently to
spreads the ointment and the pad will stick and stay in place allow time for mental processing.
while you finish the dressing.” • Keep medical terms to a minimum and explain those you do
She watches while the patient places the Telfa. use. Use specific terms when giving directions.
Nurse: “Great. Now open another pack of gauze squares like I • Ask questions at frequent intervals to check for comprehen-
showed you. Put those on top of the Telfa and tape every- sion.
thing down.” • Allow time for questions.
Mrs. Dunn: “It’s really important to get the tape ready first. • State the most important points first, and repeat them at the
Otherwise, you’d run out of hands!” end of the session.
Nurse: “Exactly. Now, after each dressing change, you wash

your hands again, and then you are done. See how well you
did? Do you feel better about doing this now?” Never assume that patients are literate. Many adults
Mrs. Dunn: “Quite a bit. I still feel all thumbs, though, and I have gotten through school without learning to read
worry about getting the sore clean enough by myself.” adequately, and they may have spent a lifetime hiding
Nurse: “I think having some pain medicine will help. I’ll bring this fact from friends, employers, spouses, and chil-
your acetaminophen around 1:00, and we’ll do the dressing dren. A teaching plan that incorporates visual and kin-
again about 2:00.” esthetic techniques will often be the most effective for
Mrs. Dunn: “OK, and thank you. My husband will be here then. these individuals.
Is it okay if he watches?”
Some patients who speak English as a second lan-
Nurse: “Absolutely. He can help you when you get home.”
guage may not be able to read English, even if they are
fully literate in their original language. When working
It is essential that the teaching plan be developed with a patient for whom another language is primary,
collaboratively, with input from all of the disciplines offer printed and audiovisual materials in their native
involved in the patient’s care. The specifics of the plan language, if available. If English is limited, use an
should be discussed and agreed on. Each knowledge interpreter for teaching sessions.
deficit is listed as it is identified, and the date is included. When printed materials are used, go over them with
The person responsible for providing teaching in each the patient and ask questions to determine whether the
information has been understood. Be aware of the

THE TEACHING PLAN
patient’s educational level so that you can tailor your
vocabulary and teaching materials, but avoid talking Preparing a teaching plan involves analyzing the
down to people. Assess what patients already know assessment data, establishing behavioral objectives or
about the information or skills they need to learn so goals, and creating a plan for assisting the patient in
that you can build on their current knowledge base. achieving these goals in the most timely and effective
Do they have a basic knowledge of anatomy and how manner. Behavioral objectives represent the desired
the body works? What do they already know about changes or additions to current behaviors and atti-
their medications? If they are going to give their own tudes. They state what you are trying to teach the
injections, have they ever handled a needle and syringe patient to do. “Patient will change the wound dressing
before? Teaching is most effective when you can relate using aseptic technique” is a behavioral objective.
the material to a subject that patients already under- Behavioral objectives should be stated in terms that
stand. It can also be helpful to determine whether they make their achievement easy to evaluate. The above
have a relative or close friend who is knowledgeable objective would be evaluated by watching the patient
about their health issues and willing to help them after change the wound dressing and determining whether
discharge. correct aseptic technique was used.
The teaching plan is part of the care plan. Some
Readiness to Learn agencies use a separate form for the teaching plan so
Assess the patient’s readiness to learn. Motivation that there is plenty of room to note the specifics. Spe-
plays a large role in effective learning. The desire to cialty areas may have a standardized teaching plan. An
return to independence or to return to the comfort of example would be postpartum teaching plans for self-
home is often the motivating factor. Work with patients care after delivery or for basic infant care.
to show them the advantages of learning what they
need to know. Teaching sessions will be more success- RESOURCES FOR TEACHING
ful if the patient is comfortable and rested and there Many books and articles provide suggested methods
are a minimum of interruptions. and teaching aids for particular topics. Audiovisual
materials, pamphlets, and hands-on equipment are
Clinical Cues also good resources. Become familiar with what is
available in your facility. Many agencies have closed
If the patient is in a double room and the roommate has several
visitors who are making noise, take the patient to the confer- circuit TV teaching modules available on the room
ence room or other location for the teaching session to pro- televisions. Community agencies may also provide
mote better communication and reduce distractions. educational tools. Local government agencies often
provide printed and online listings of community pub-

Begin by establishing rapport and developing trust, lic service programs. Nursing specialists may be avail-
and maintain a warm, sincere attitude. able to assist with information and teaching plans or to
Although several nursing diagnoses can be used for do the actual teaching. Hospital social workers and
learning needs, the most commonly used one is Defi- patient representatives are also good sources of infor-
cient knowledge; the specific need finishes the statement mation about what is available.
(Box 9-2). Some instructional materials are designed to assist
the medical professional, and others are directed to the

patient. The Internet has a wide variety of resources
NANDA-I Diagnoses Related to Teaching available for patient teaching. An Internet search by
Box 9-2 topic will provide links to myriad resources. Leading
and Learning
medical centers and universities across the United
Examples of NANDA-I diagnoses that indicate the need States and Canada, as well as governmental agencies
for teaching* include: such as the National Institutes of Health (NIH), the
• Deficient knowledge Centers for Disease Control and Prevention (CDC),
• Ineffective health maintenance and the National Institute of Mental Health (NIMH),
• Readiness for enhanced self-health management
have websites with excellent teaching resources.
• Readiness for enhanced knowledge
• Readiness for enhanced parenting IMPLEMENTING THE PLAN
• Readiness for enhanced self-care
• Readiness for enhanced sleep Begin by establishing a time with the patient to begin
the teaching. Teaching should be done at a time when
*Any “Risk for…” diagnosis may indicate a need for teaching to decrease the
risk.
visitors, physician rounds, and treatments will not
Nursing Diagnoses—Definitions and Classifications 2012–2014 © 2012, 2009, cause interruptions. Teaching can be done one-on-one
2007, 2005, 2003, 2001, 1998, 1996, 1994 by NANDA International. Used
by arrangement with Wiley-Blackwell Publishing, a company of John Wiley
or in a group setting. Be certain that the room tempera-
& Sons, Inc. ture is acceptable and the patient is comfortable.
Medicate the patient before the teaching session if pain what has been taught. If teaching occurs over several
control is needed. Provide good lighting. Be certain he sessions, each teaching session should begin with a
can hear you and can see adequately. review of what was previously learned. If the patient
Keep the teaching session short. Involve the patient was taught a specific skill, such as drawing up insulin,
in the process; call him by name, and ask for feedback have the patient demonstrate that skill. This is called a
as you progress. If teaching a group, establish eye con- return demonstration.
tact frequently with each person in the group. Pause at
intervals and ask if there are questions. When teaching EVALUATION
a procedure, talk about the steps of the procedure, Evaluating the effectiveness of teaching is critical to
demonstrate the procedure, and then talk patients the success of the process. It involves giving and
through each step while they perform it (Figure 9-1). obtaining feedback (return of information about the
Have them write down the steps, or provide them with process) from the patient regarding what was taught,
a written guide they can follow. then using this feedback to determine whether effec-
At times, you may need to incorporate teaching into tive learning has in fact taken place. A return demon-
daily care. Teaching patients to perform range-of- stration of a skill is one way of evaluating the
motion exercises on their weak extremities can be done patient’s learning. Point out what steps were done
while bathing. Teaching about wound care can accom- correctly and gently make suggestions about needed
pany the process of changing the dressing. Reinforcing corrections in the procedure. When the patient is
information about a medication can be done when learning information rather than a skill, ask ques-
administering the medication. tions to obtain feedback about retention and compre-
The patient needs to receive written or printed hension of the material taught. Allow the patient
information about what has been taught to take time to think through the answers. Let the patient
home—for instance, a pamphlet or clearly written list use any printed materials handed out. This shows
of steps to accomplish a procedure, such as performing you that the patient can appropriately use the
a blood glucose determination. When possible, this resources you provided. Make positive comments
should be in the patient’s primary language. about the retained information.
Legal & Ethical Considerations Elder Care Points

Use of an Interpreter Writing down the steps of a procedure helps all learners focus.
Health care facilities must use an interpreter or a telephone It is particularly helpful for assisting the elderly person in
interpretation service when obtaining a history or providing increasing and integrating the information. It also aids recall of
necessary patient instruction to someone who does not have a the information and assists in diminishing any sensory distrac-
language in common with the health care staff. tion such as background noise.

Allow patients to perform at their own speed. The If the return demonstration or the review questions
first step is learning to do the skill correctly. Perfor- indicate that the patient has not mastered the skill or
mance will become more rapid with practice. Learning material taught, you will need to repeat the instruction
is a process of many steps, and rushing these steps can and reevaluate performance before going on to a new
cause confusion, frustration, and a sense of failure for area of teaching. It may also be necessary to alter the
both the patient and the nurse. Plan a time to review method of teaching to more effectively use the patient’s
strongest learning strategies. The teaching plan should
be adjusted and updated according to the evaluation
data obtained. New learning needs may also be identi-
fied during the teaching and evaluation sessions. These
need to be included in the teaching plan.
DOCUMENTATION
Teaching often occurs informally while performing a
nursing task such as administering medications. This
makes it a challenge to consistently document patient
education. Every staff nurse is legally responsible for
providing patient education, and documentation is
essential. If the facility does not use a patient education
flow sheet, the following information should be
entered into the nurse’s notes: specific content taught,
the method of teaching that was used, and evidence of
FIGURE 9-1 Nurse teaching patient how to draw up insulin. evaluation with specific results of the teaching. This
allows nurses providing continuing care for the patient In addition, the family or significant others who will be
to follow up and reinforce the teaching. caring for the patient may need to be included in some
of the teaching sessions. When the patient lives alone,
it is important to accurately assess whether he has the
COORDINATION WITH DISCHARGE PLANNING motor skills necessary to care for himself. Specific
Patients may be discharged home before necessary learning needs that remain should be discussed with
learning is complete. Information regarding the all involved parties, including the patient, and the plan
patient’s education needs to be communicated to the for teaching shared. Send a printed plan home with the
primary physician’s office. If the patient is being patient. A telephone call to the home health agency or
referred for home health services, it is necessary to also to the physician’s office helps provide continuity of
communicate the information to the home care nurse. teaching.
Key Points Additional Learning Resources

• Nurses continually teach patients about aspects of their SG Go to your Study Guide for additional learning activities to help you
disease or disorder, diet, medications, treatment, and master this chapter content.
self-care.
• Patient teaching is a major part of patient care. Go to your Evolve website (http://evolve.elsevier.com/deWit/
• There are three methods of learning: visual, auditory, and fundamental) for the following FREE learning resources:
kinesthetic. • Animations
• The first step in teaching is to assess what the patient • Answer Guidelines for Think Critically boxes and Critical Thinking
needs to know (learning needs, knowledge deficits). Questions and Activities
• Many factors can affect learning: physical limitations, • Answers and Rationales for Review Questions for the NCLEX®
situational factors (including pain), readiness to learn, Examination
personal values and expectations, age, attitude, and • Glossary with pronunciations in English and Spanish
ability to comprehend. • Interactive Review Questions for the NCLEX® Examination and more!
• Environmental factors such as room temperature, noise
level, lighting, and interruptions by others can affect Online Resources
learning. • Health Goals for Canada, www.phac-aspc.gc.ca/hgc-osc/new-1-
• Establishing rapport and mutual trust are essential to eng.html
effective teaching. • Healthy People 2020 Goals and Objectives, www.healthypeople.gov/
• A teaching plan is devised and documented based on the 2020/topicsobjectives2020/default.aspx
patient’s learning needs. Patient Education Materials
• Learning needs must be prioritized to ensure that patients • www.medicalcenter.osu.edu/patientcare/healthcare_services/otolaryngo
learn those things most important to safe self-care before logy/otolaryngology_patient_education/Pages/index.aspx
discharge. • www.upmc.com/healthAtoZ/patienteducation/Pages/patiented.aspx
• Books, articles, pamphlets, audiovisual materials, and
demonstration equipment are good resources for
teaching. Nursing specialists are another resource. Review Questions for the NCLEX® Examination
• Including the patient in the development of the plan will Choose the best answer for each question.
help keep the patient involved in the education process.
• Teaching may occur one-on-one or in a group setting. 1. Evidence that the primary purpose of patient teaching
• Evaluating the effectiveness of teaching is critical to the has been achieved is that patients:
success of the process. 1. share with others what they have learned.
• To evaluate, obtain feedback from the patient either by 2. reduce the time they are hospitalized.
question and answer or ask for a return demonstration. 3. follow the treatment plan prescribed.
• Documentation of patient teaching and the learning 4. provide correct and safe self-care after discharge.
achieved is a legal responsibility and should be done
consistently. 2. There are three types of learning: auditory, visual, and
• Collaboration with other health care professionals kinesthetic. Learning to apply an ostomy appliance by
involved in the patient’s care is essential for uniformity doing it step by step is an example of _______________
and continuity of teaching. ___________________ learning. (Fill in the blank.)
3. A patient newly diagnosed with diabetes has stated that 8. To overcome barriers to learning for a hearing impaired
he doesn’t understand why he needs insulin. His person: (Select all that apply.)
statement indicates a learning need regarding: 1. make certain there is adequate light in the room.
1. the disease process of diabetes. 2. be certain the hearing aid is turned on and adjusted.
2. the types of insulin available. 3. eliminate other noise in the room as much as
3. the diet a diabetic needs to follow. possible.
4. the role weight management plays in treatment. 4. provide colored pictures of the steps of the proce-
dure being taught.
4. When starting the second teaching session for a 5. speak loudly, repeating each statement.
patient, the nurse should first: 6. gain the patient’s attention and speak in a normal
1. present the new material to be covered in this low tone while facing him.
session.
2. question the patient about learning from the first 9. When choosing written materials for an elderly patient,
session. the nurse should choose:
3. briefly review what was taught in the first session. 1. yellow paper with 12-point black print.
4. review the entire teaching plan. 2. green paper with 12-point black print.
3. glossy white paper with large black print.
5. When first teaching a young child about insulin injec- 4. white nonglossy paper with enlarged black print.
tions, it is appropriate to:
1. teach in a group setting. 10. The most important objective for a patient who needs
2. use a needle, a syringe, and an insulin vial. to learn about a dressing change is, The patient will:
3. use a doll to demonstrate an insulin injection. 1. gather all needed supplies before beginning proce-
4. set firm limits on behavior while teaching. dure.
2. remove the old dressing and discard it.
6. When teaching the elderly about a needed diet change, 3. use aseptic technique for the dressing change.
to reinforce the information: 4. change the dressing only when it is visibly soiled.
1. write down the diet instructions.
2. speak loudly.
3. show pictures of various foods. Critical Thinking Activities
4. play old tunes in the background. Read each clinical scenario and discuss the questions with
your classmates.
7. An appropriate patient teaching plan:
1. is prepared by the nurse based on the patient’s Scenario A
diagnosis. Identify factors that you think might interfere with learning
2. designates 15-minute segments of teaching time. for a patient.
3. includes input from all disciplines involved in the
care, as well as from the patient. Scenario B
4. must be approved by the patient’s family members. Discuss cultural or religious beliefs that you think might
have a direct impact on the patient’s teaching plan.
Scenario C
Assess the learning needs of three patients, and then share
commonalities of those needs with your clinical group.
chapter
Delegation, Leadership, and Management 10

Objectives
1. Differentiate between the three different leadership styles 1. Determine the leadership style of the charge nurse on the
discussed in the chapter. unit to which you are assigned.
2. Compare and contrast examples of effective and 2. Appropriately delegate three tasks to a nurse’s aide
ineffective communication. or UAP.
3. Describe four characteristics of an effective leader. 3. Create a time-efficient work organization plan for a shift.
4. List four considerations for delegating tasks to unlicensed 4. Demonstrate proficient use of the hospital computer.
assistive personnel (UAPs). 5. Accurately and carefully transcribe orders per facility policy.
5. Explain why interpersonal relationships are important when 6. Document accurately for reimbursement.
delegating and managing others. 7. Know your facility’s policies and procedures and uphold
6. Distinguish the skills and functions of the team leader with the standards of nursing practice.
those of the charge nurse. 8. Find a mentor who can coach you on improving your
7. Identify management functions of the LPN/LVN working delegation and management skills.
in a long-term care facility, home care, or an outpatient
clinic.
8. Discuss techniques of effective time management.
9. Explain the importance of the readback for verbal or
telephone orders.
Key Terms
accountable (p. 126) laissez-faire (LĔS-ā-FĀR, p. 124)
authority (p. 125) mediate (MĒ-dē-āt, p. 125)
autocratic (aw-tō-KRĂ-tĭk, p. 124) mentor (p. 131)
collaboration (p. 124) responsibility (p. 124)
competence (p. 125) risk management (p. 131)
confidence (p. 125) self-esteem (p. 125)
conflict resolution (p. 125) stat orders (p. 129)
constructive criticism (p. 127) unlicensed assistive personnel (ŭn-LĪ-sĕnst ă-SĬS-tĭv

delegate (p. 124) pĕr-sŏ-NĔL, p. 124)
democratic (p. 124)
interpersonal relationships (p. 124)
The LPN and LVN are taking on more and more lead-
THE CHAIN OF COMMAND
ership functions, particularly in the skilled nursing
facility. Leadership is a comprehensive process that Once you are hired, become familiar with the organi-
includes the guidance of staff and the effective use of zational structure of the facility where you work. This
resources to meet patient needs. Leadership requires a information is provided during your formal orienta-
good understanding of one’s self and a good grasp of tion. Be certain you know the chain of command for
basic management techniques. This chapter discusses your area. Who is your immediate supervisor? From
management skills and leadership qualities that the whom do you take orders? To whom does your super-
LPN/LVN needs to be effective during the first year visor report? To whom should you report changes in
after graduation. patient condition or signs of complications? To whom
123
do you go with concerns or complaints? Who is in Box 10-1 Attributes of a Good Leader
charge of scheduling? What is the procedure for calling
in sick? • Ability to teach • Flexible
• Active listener • Good role model
• Articulate • Good sense of humor
LEADERSHIP STYLES • Assertive • Objective
• Calm • Open minded
Most leaders employ a blend of leadership styles. • Considerate • Organized
A permissive or laissez-faire leader does not attempt to • Consistent • Responsible
control the team and offers little if any direction. This • Decisive • Sensitive
leader assumes that team members are competent and • Excellent clinical skills • Strong character
self-directed and will do what needs to be done cor- • Excellent problem solver • Tactful
rectly and efficiently. This leader often has a need to be • Fair
liked by everyone and therefore avoids any blame for
things that go wrong by allowing members to function
completely independently. Although this leadership Collaborative practice includes learning to work effec-
style usually is not effective in the day-to-day manage- tively with unlicensed assistive personnel (UAPs).
ment of patient care operations, it can be effective UAPs include unit secretaries, nursing assistants,
in certain situations involving a highly motivated, homemaking aides, housekeeping personnel, and tech-
highly creative group that works well with minimal nicians. To collaborate with UAPs, you must learn to
guidance—for example, a committee. delegate (entrust to another) tasks appropriately and
The authoritarian or autocratic leader tightly con- effectively.
trols team members. Staff members are rarely con-
sulted when decisions are being made. Rules are set EFFECTIVE COMMUNICATION
without input from the staff, and directives and orders AND RELATIONSHIPS
are given out constantly. This type of leadership style Leaders use good communication skills and recognize
has been described as “my way or the highway.” The that every team member has a valuable role in patient
leader closely supervises the work of each staff mem- care. Communicating in direct, concise terms in a
ber. When mistakes are made, they are quickly pointed tactful, friendly, nonthreatening way is essential to
out. The leader’s goal is accomplishment of tasks effi- create a supportive and healthy work environment.
ciently without regard to people. Obtaining feedback about directions given and listen-
The democratic leader consults with staff members ing actively to reports, suggestions, and complaints
and seeks staff participation in decision making. The establishes a pattern for two-way communication. This
team members’ skills and knowledge are readily used helps the leader stay in tune with the atmosphere, atti-
to ensure efficient team functioning. Team members tudes, and problems of others on the health care team.
are respected as individuals, and there is an open and Showing care and concern for team members can help
trusting attitude. The democratic leader is part of the develop positive interpersonal relationships that pro-
team, not above it, and accepts responsibility for the mote team cooperation. Relationships and trust
team’s actions. develop over time through conversations and interac-
There is no one set of qualities that makes a good tions. The Joint Commission emphasizes the impor-
leader. Box 10-1 lists responses that nurses have given tance of communication by health care providers in
when asked what they think makes a good leader. one of its National Patient Safety Goals.
Such a leader instills confidence, trust, and spirit in the
team. Appropriate leadership fosters growth among
the team members. Safety Alert
National Patient Safety Goal 2
Think Critically The Joint Commission has set the following goal for health care
facilities: “Improve staff communication.”
Consider what leadership qualities you have and what qualities
Components of this goal include, “Get important test results
you would aspire to achieve. With what type of leader would
to the right staff person on time.”
you prefer to work? Why? When would autocratic leadership
be important? Why? Source: The Joint Commission. (2012). Hospital National Patient Safety Goals.

Retrieved from www.jointcommission.org/assets/1/6/2012_NPSG_HAP.pdf.
ISBAR-R communication (see Chapter 8) is a com-

KEYS TO EFFECTIVE LEADERSHIP
munication tool that many institutions are adopting to
As an LPN/LVN, you will be expected to work with improve communication among staff. See the Evolve
other members of the health care team. Collaboration website for the following useful communication tools
(working together) is essential for patient care. and strategies: Advocacy and Communication, Charge
Delegation, Leadership, and Management CHAPTER 10 125
Mediate (settle differences) by communicating openly.

Sort out the issues involved by identifying key themes
in the discussion. Consider the options and weigh the
consequences of each option. Choose the option for
conflict resolution (resolving a conflict) that offers the
best outcome.
CLINICAL COMPETENCE AND CONFIDENCE

As a nurse leader, you must demonstrate competence
(being well qualified) in your nursing skills. Confidence
(belief in yourself) in the ability to perform those skills
is essential to gain the respect of the other team mem-
bers. Along with this competence and confidence
should be sufficient self-esteem (pride in yourself) to
readily admit when a mistake has been made or when
you don’t know something. Announcing “I don’t know,
but I will find out” is the best way to handle these situ-
ations. Others will respect you more if you admit that
you don’t know everything; this shows that you are
human and provides an atmosphere in which others
FIGURE 10-1 Charge nurse delegating a task to a staff nurse.
can admit what they don’t know and can ask for help.
Nurse Communication Strategies for Communicat- ORGANIZATION

ing Information with the Team, and Tips for Conflict Being a leader requires good organization. Organizing
Resolution. the work of a unit requires strong time management
Communicating effectively includes taking the time skills. Plan each day carefully, with some built-in flex-
to attend to the person by stopping what you are doing, ibility for unforeseen events. Knowing the strengths of
establishing eye contact, being polite by saying “please” each member of the health care team helps you more
and “thank you,” and using a warm tone of voice effectively divide the workload. Decision-making abil-
(Figure 10-1). A smile adds warmth to the interaction. ity is needed to quickly divide up patients and assign
Saying, “I would like you to take vital signs on the right tasks to various personnel.
side of the hall, please,” rather than “Go and take vital Problem-solving skills provide the means for mak-
signs on that side of the hall,” usually enlists better ing difficult decisions. The problem-solving process is
cooperation and a more pleasant attitude toward the much like the nursing process. The good problem
task. Your style of communication and actions also solver first defines the problem (assessment), then
reflect your trust and respect toward others. Consider looks at the alternatives. The outcomes of using each of
the other person’s culture and how it may affect verbal the alternatives are estimated (planning), and then one
and nonverbal communication (see Chapter 8). Treat of the alternatives is chosen to be tried as the solution
others how you would like to be treated. to the problem (implementation). If the alternative
When assigning tasks, be specific about what is to chosen does not solve the problem, then the whole pro-
be done, how it is to be done, and when the task is to cess is repeated (evaluation). Please see the section
be completed. It is better to say, “Please take Mrs. “Critical Thinking” in Chapter 4.
Jones’ temperature at 2:00 p.m. and let me know right
away what it is so that I can let her physician know,” DELEGATION
than to state, “Mrs. Jones’ temperature needs to be In beginning the discussion of delegation, it is helpful
taken at 2:00 p.m.” Likewise, it is better to say, “Tell me to contrast it with the term assignment. Assignment of
immediately if Mr. Hernandez’s temperature is above tasks is a method of distributing the unit’s workload,
101.2° F,” than “Let me know if Mr. Hernandez’s tem- usually by the charge nurse. In assignment, the nurse
perature is high.” Ask if there are questions before directs the UAPs to complete tasks within their job
ending the interaction, and follow up to make certain description—tasks they are hired and paid to perform.
the task was completed on time. Avoid conflict by This always occurs at the start of the shift, but may also
being thorough when giving directions, making a occur at any time during the shift. In contrast, delega-
request, or assigning a task. If a conflict does arise, try tion occurs when a licensed nurse transfers the author-
to remain calm and open and actively listen to the ity to perform a selected nursing duty in a selected
problem. Accept responsibility for any part you patient situation. In delegating a task to a UAP, you
played in development of the conflict. Focus on the are, in essence, “sharing” power with your UAPs.
issue rather than on the feelings of those involved. Many states do not allow LPN/LVNs to delegate, and
even in a state where it is allowed, you must also be Tasks That Can Be Delegated to Unlicensed
certain that delegation is allowed in your facility. Box 10-2
Assistive Personnel (UAPs)*
Delegation is done with careful thought; for exam-
ple, it is not appropriate to delegate a nursing duty • Applying a condom catheter
simply because you dislike it. Furthermore, you must • Applying a hearing aid
be certain that the individual to whom you are about to • Applying cold packs
• Applying elastic stockings
delegate is competent to perform such a duty (written
• Applying warm compresses
evidence of competence is best, to be described shortly), • Assisting to deep breathe and cough
that the patient situation is stable, and that the task has • Assisting with ambulation
a predictable outcome. • Giving a bath
You are accountable (must answer) for the tasks you • Bed making
delegate, if in fact you are permitted by law to dele- • Blood glucose monitoring
gate. Legally, you are responsible and accountable for • Collecting specimens
the outcome of any task you delegate to another. Dele- • Emptying drainage containers
gating appropriately means that you must (1) know the • Feeding patients
capabilities and competencies of the person to whom • Filling water pitchers
you are delegating, (2) know whether or not the task • Giving a sitz bath
• Giving an enema
falls within the domain of tasks that can legally be del-
• Giving a vaginal douche
egated by you, (3) communicate effectively with the • Measuring weight and height
person to whom you are delegating, and (4) understand • Measuring vital signs
the patient’s needs. • Performing oral hygiene
Before any tasks are delegated to a nursing assistant • Performing range-of-motion exercises
or other UAP, that person should be thoroughly ori- • Providing hair care
ented to the facility and the unit. Competencies of • Providing skin care
unlicensed personnel must be documented before • Recording intake and output
tasks are delegated to them. This requires evidence of • Removing a Foley catheter
a training program and written evidence by a quali- • Repositioning patients
fied nurse or instructor that the person has demon- • Stocking supplies
• Taking specimens to the laboratory
strated competence in the task or skill. If you do not
• Toileting patients
have access to such written documentation, it is best to • Transferring patient to a chair or bed
observe the UAP perform the task or skill the first time • Turning patients
you delegate it to verify that a level of competence has
been reached. If the task has not been a part of the *May vary from state to state and facility to facility.
UAP’s formal training program, then you should dem-

onstrate how the task should be done and ask for a UAP job descriptions before you delegate a task. It is
return demonstration. Within the area of general com- up to you to know what the UAP cannot do. The
petencies, the UAP should be assessed for competence agency’s policies and procedures and the standards of
in patient safety issues such as infection control and practice for your area of nursing help to define what
moving and positioning patients. the UAP is allowed to do (Box 10-2). Assessment or
aspects of the analysis, planning, or evaluation

Think Critically phases of the nursing process must be performed by
the registered nurse (RN). These functions cannot be
How would you tactfully tell a UAP that you would like to see
delegated to unlicensed personnel. Most tasks that
him perform a particular task before assigning him to do it on
his own? are delegated to UAPs are technical, repetitive skills

that have a predictable patient outcome. Interventions
that require professional judgment should not be
Be familiar with your state’s nurse practice act so delegated.
that you know what tasks and skills fall within your It is important to remember the goal and purpose of
legal domain. This tells you what you must not dele- delegation. Nurses delegate to complete more work in
gate. In addition, some professional nursing organiza- the same time frame. However, delegated work must
tions, such as the American Association of Critical-Care be done safely, correctly, and cost-effectively. Effective
Nurses (www.aacn.org), have documents that outline delegation includes giving feedback on how the task
examples of tasks that might be appropriate for dele- was performed. Give praise where it is due; share
gation; however, you must ensure that this matches favorable comments from patients about the UAP’s
what is allowed in your state. Your agency should have work and interactions. If the delegated task did not go
a job description that spells out what the UAPs can and as expected, communicate exactly what went wrong in
cannot do. Be certain that you are familiar with the a supportive manner. Provide privacy before giving
criticism. Be tactful. You might share that the patient

was upset that it took three tries for the UAP to obtain
an accurate blood pressure. Asking, “Do you think you
need some more supervised practice and suggestions
on how to take blood pressures smoothly? Would you
like me to demonstrate it again?” allows the UAP a
face-saving way to admit that more instruction is
needed. Ask what might help the UAP perform better
the next time.
When giving constructive criticism, begin by tact-
fully acknowledging feelings or expressing empathy.
Statements such as, “I understand that we are one aide
short today,” begin the interaction on a less threatening
note. Next describe the behavior. An example would
be, “I’ve noticed that on three mornings this week it
has been 9:30 a.m. before vital signs you took were
posted.” Then state the expectation for future compli-
FIGURE 10-2 Charge nurse discussing a new procedure with staff.
ance, such as “The vital signs need to be posted no
later than 8:30 a.m. from now on.” Finally, state the
consequences if the expected action does not occur.
This can be done by stating something like, “The phy- scheduling of patients, performing quality assurance
sicians and medication nurses have to track you down audits, training staff, evaluating staff, coordinating
when the vital signs are not posted on time. This can team members to accomplish the daily work, assisting
affect patient safety and care. If posting is late again, in writing policies and procedures, attending staff
I will have to document your inability to complete the meetings, and resolving staff conflicts (Figure 10-2).
task on time.” When performance by a UAP has been
poor, document the specific facts (not your opinions). Think Critically
The unit manager should also be made aware of the What leadership functions do LPN/LVNs perform in the facility
performance problem. in which you are assigned for clinical experience?
When delegating a variety of tasks, help the UAP
prioritize the order in which they should be done. It

takes many months for most UAPs to be able to dis- ADVANCED LEADERSHIP ROLES
cern which tasks take priority over others. Eventually the LPN/LVN may become a charge nurse
The patient must be told when an unlicensed person or a supervisor of UAPs in settings such as home care
will be performing some tasks that were formerly only or outpatient clinics. A charge nurse must have train-
performed by nurses. This is within the domain of a ing and experience in nursing administration and
patient’s rights. Simply tell the patient that you, the supervision plus additional preparation in a special-
nurse, have primary responsibility for the care given, ized area in many states. A minimum of 1 year of staff
but that the UAP is your assistant and will be doing nurse experience is often required before taking on
certain tasks. charge nurse duties. However, sometimes life experi-

ence in other roles can speed up the assumption of the
LEADERSHIP ROLES leadership role.
The ability to recognize significant changes in
BEGINNING LEADERSHIP ROLES patient condition and to take necessary action is a pri-
Initially, the new LPN/LVN performs leadership func- mary quality in a charge nurse. The charge nurse is the
tions in working with UAPs, including delegation of manager’s designee and has all of the manager’s
tasks and supervision of the UAPs’ work. Later, after authority for the shift; he is responsible for the total
being thoroughly oriented to the facility and its poli- nursing care of the patients on the unit during the
cies and demonstrating competence, team leading may shift.
be required. A team leader coordinates and makes In a long-term care facility, the charge nurse receives
assignments for other personnel, assists with patient the report from the previous shift, makes patient
care, helps resolve conflicts, assists in writing policies assignments, makes rounds and assesses all patients,
and procedures, contributes information for evalua- directs the administration of medications and treat-
tion of UAPs, and collaborates with physicians and ments, confers with team members throughout the
other health team members. shift, and reports to the oncoming shift on patient sta-
When working in a medical clinic, the LPN/LVN tus. Charge nurses may also oversee training of UAPs
team leader is often responsible for overseeing the and evaluate the unit’s health team members.
MANAGEMENT SKILLS FOR THE LPN/LVN SHIFT WORKSHEET
All nurses are expected to be able to manage time, use Initials:

a computer, order supplies, transcribe orders, place Report notes:
telephone calls to physicians and families, process ver- Room #:
bal orders, and document care appropriately, includ- Allergies:
ing for reimbursement of patient costs. Notify MD for:
An LPN/LVN working in a home care agency may VITAL TREATMENTS/
TIME ASSESSMENTS MEDICATIONS SIGNS PROCEDURES
be asked to assign and supervise nursing assistants
and home health aides, including making patient care
0700
assignments, assisting with orientation and evalua-
0800
tion, verifying that paperwork ensuring reimburse-
0900
ment is correctly completed, and giving and receiving
reports on assigned patients. 1000
1100
TIME MANAGEMENT 1200
Leaders need to use time efficiently. Learning certain 1300
techniques will help with your time management. 1400
Begin each workday by making a “to-do” list before 1500
the shift starts, providing a loose structure for the day.
Formulate one or two broad goals for the day.
The goal for the home care nurse might be “to com- OXYGEN DIET IV FLUIDS ACTIVITY DRESSINGS I&O LABS
plete four visits by lunchtime.” This would involve

organizing and planning the most efficient order for
patient visits, gathering all needed supplies, notifying
each patient of the approximate time of the visit, orga-
nizing paperwork to be completed, and making cer- FIGURE 10-3 Sample time management tool. Use one page per
patient or create your own tool and put several patients on one page.
tain the car has gas.
Organizing for the workday in a medical clinic var-
ies depending on the type of clinic and the nurse’s and room number. Note times you will delegate tasks,
assigned duties. The goals for a clinic nurse might be to assess patients, check intravenous (IV) lines, give treat-
“ensure rooms are stocked and set up for treatments, ments, turn patients, document care, perform teaching,
and patients are roomed in an efficient manner.” Pull prepare for the end-of-shift report, and so on. Docu-
charts for patients scheduled to be seen, replenish sup- mentation is a critical task in all settings and must be
plies in examining rooms, and so forth. considered a priority to be done as soon as possible
For the staff nurse in the hospital, the shift’s goal when organizing to accomplish the daily workload.
might be to “ensure that all assigned patients are kept Use a separate grid to note when medications are
comfortable and safe and that all scheduled treatments due for each patient. Use this sheet to note when you
and medications are given.” After you receive the shift give PRN (as needed) medications. That way you have
report and obtain patient assignments, set your priori- a quick refresher for charting the PRN medications in
ties. Start by identifying the patients with the most sig- the progress notes. As you work throughout the day,
nificant or life-threatening problems. Which patients you can make small notes on your work organization
are physically unstable and need to be checked fre- sheet that will provide data and a guide for charting.
quently? Which patients have frequently scheduled Next consider tasks that need to be done sometime
treatments? Which patients are at highest risk for com- during the shift, such as checking the “crash” cart.
plications? Which patients are at risk for injury because Note on your work schedule when you think you will
of confusion? Set priorities according to patient need. have time to do that. Finally, consider activities that
Unstable patients take precedence over stable patients. you would like to do if time permits, such as spending
Administer scheduled medications and treatments time talking with a lonely patient, giving a back rub, or
before tasks that are ordered “three times per day.” making a phone call to a patient’s family. Note these at
The goal for the long-term care nurse might be to the bottom of the worksheet.
“delegate and coordinate care of assigned patients to Once the work is organized, begin your patient
finish all scheduled tasks on time and keep the patients assessment/data collection rounds. Do this early in the
safe and comfortable.” shift. Patient status can sometimes change dramatically
Take a few minutes before making rounds to devise a during shift change. Quickly gather data regarding
time schedule for the work of the shift (Figure 10-3). Use each patient’s area of greatest problem (usually their
a grid that shows each hour of the shift and each patient admission diagnosis). Check all tubes and equipment
attached to the patient. You will be able to do more in- orders first, and verbally communicate them to the
depth observations later in the shift. Right now you nurse responsible for carrying them out. Transfer the
just need to determine whether there are any emergen- orders to the computer care plan and electronic medica-
cies, get a feel for the patients’ status and needs, and tion administration record (eMAR) (or Kardex, medica-
determine what equipment and supplies you will need tion and treatment cards, and paper MAR if used). Each
for each patient during the shift. Inquire about the need medication order must include the patient’s name and
for pain medication or other PRN medication while room number, the name of the medication (preferably
initially in the room. These then can be brought back both generic and trade name), ordered dosage, route of
during early morning medication rounds unless the administration, the times the doses are to be given, the
medication is a badly needed analgesic; this should be date the order was written, and the date it is to be dis-
administered immediately. continued and/or renewed. Check off each order as it
At the end of the workday, evaluate the effective- is transcribed. Narcotics, anticoagulants, hypnotics,
ness of your time management. Did your schedule and antibiotics must be renewed every 48 to 72 hours,
help? Did it work as well as you had planned? What depending on agency policy and state laws. Sign off the
took more time to complete than you thought it would order with a red line across the page under the physi-
take? What would you do differently if you could have cian’s signature and your first initial, last name, and offi-
a “do over”? This analysis helps you to create a more cial designation, or according to agency policy. Include
workable plan the next time. Keep in mind that work the date and the time. Notify the person who will be
plans must be flexible. Even the best plans can be giving the medication per the new order. Transmit the
destroyed if one patient’s status deteriorates markedly. order to the pharmacy by phone, fax, or computer and
This happens to all nurses from time to time. follow with a hard copy. In some facilities, you may then
write “faxed to pharmacy 2PM,” with your initials,
Think Critically before returning the original form to the chart.
Dietary orders are transmitted to the dietary depart-
Can you design a shift time management sheet that suits your
work style and needs? ment and entered on the Kardex or computer care plan

along with notations for any fluid restrictions or
requirements for intake and output (I&O) recording. A
USING THE COMPUTER list of patients on I&O may be kept at the nurses’ sta-
Computers are used in all health care facilities. The tion. Clarify any unclear orders directly with the order-
nurse must become proficient in their use to perform ing physician. When medications arrive from the
everyday functions for patient care and unit adminis- pharmacy, check them against the physician’s orders
tration. The computer is used to place orders to the before placing them in the patient’s drawer or bin. This
various departments for supplies, medications, diets, may be completed by a pharmacy technician. Because
laboratory and diagnostic tests, and engineering and of frequent changes in orders, all medication orders on
housekeeping needs. Surgery and procedures are the MAR/Kardex should be verified with the chart
scheduled by computer. Staffing patterns may also be orders once every 24 hours.
scheduled by computer. Nursing care plans are con- Note any positioning, I&O, treatment requirements,
structed on the computer. Acuity levels for patients are and use of special equipment on the Kardex or the
tracked. The agency census is compiled on the com- computer care plan for each patient. Note allergies on
puter. Laboratory results are sent to the unit via com- the MAR sheet and on the front of the chart to alert
puter. The U.S. government has set a goal for all patient all personnel.
records to be electronic by 2014 (Manos, 2009). Hospi- When a medication is discontinued, cross out the
tals are adopting totally computerized patient records, item on the MAR/Kardex by marking over it with a
including medical orders, nursing documentation highlighter and writing “DC” with the date and time.
(nurse’s notes, flow sheets), and incident reports. Some agencies may use other methods for discontinu-
To be a team leader or charge nurse, you must be ation of medications; check agency policy. Notify the
adept at using the agency’s computers to efficiently nurse giving the medications for the shift. Alert the
perform all necessary job tasks. The computer is used pharmacy to the discontinuation order, and return left-
for most communication and coordination within the over doses of the medication to the pharmacy for
agency. Also, the HIPAA privacy rule (see Chapter 3) proper crediting to the patient’s account. Sign off the
mandates that we take special precautions and safe- discontinue order on the physician’s order sheet.
guard all electronic patient data, just the same as we do Orders for laboratory and diagnostic tests must be
with written patient documentation. transmitted to the appropriate department by phone
or computer with the correct requisition slip filled out.
RECEIVING WRITTEN ORDERS Stamp the forms and labels for specimen containers
When receiving newly written orders, first read all of with the patient’s identifying information. If blood
the orders. Then transcribe the stat (do immediately) samples are to be drawn when the patient is in a
fasting state, then an NPO (no food or fluid by mouth) telephone orders. According to the guidelines, institutions must
status must be transmitted to the dietary department, verify verbal or telephone orders by having the person receiving
to the nurses, and to the patient. Post an NPO sign on the order “read back” the order to the person initiating the
the door to the patient’s room. The test must be ordered order, usually the physician. This readback requires that the
person accepting the order actually write the order down in
to be drawn before the breakfast hour. Laboratory and
the chart in order to read it back.
diagnostic test orders are recorded on the Kardex or
computer care plan along with dietary restrictions and

pretest medications. The ability of the LPN/LVN to legally take verbal
Preoperative orders should include diet or NPO orders from a physician depends on state laws and the
status desired, necessary preoperative treatments, a written policies of the employing agency. Verbal
notation regarding the operative consent and the exact orders can only be taken by licensed nurses, and in
procedure to be performed, laboratory and diagnostic some states only by an RN. Some institutions stipulate
tests to be completed, patient teaching required, and that verbal orders not be taken except in emergencies.
orders for sedatives or preoperative medications. If your state and agency allow you to take a verbal
There may also be orders for the type of surgical prepa- or telephone order, follow the guidelines in Box 10-3.
ration to be performed and when, insertion of an IV The nurse enters it on the physician’s order sheet and
cannula and what solution is to be started, insertion of marks it “V.O.” (verbal order) or “T.O.” (telephone
a Foley catheter, or application of elastic hose. All order) with the date, time, first initial, last name, and
orders written preoperatively are considered can- professional designation (LVN or LPN). The physician
celed at the time the patient enters surgery. Brand must sign the written form of the verbal order as
new orders must be written in their entirety for the soon as possible.
postsurgical patient. “Resume previous orders” is not
acceptable by most institutional policies. DOCUMENTING FOR REIMBURSEMENT
Postoperative orders should include a schedule for All nurses must document care delivered and equip-
vital sign measurement; directions for care of tubes, suc- ment used for a patient; otherwise the hospital may
tion, and dressings; IV solutions to be infused; medica- not be reimbursed. A charge nurse or supervisor makes
tions to be administered; diet permitted; measurement certain that all staff are documenting correctly. Each
of I&O; directions for positioning, activity, turning, type of agency has guidelines regarding the details of
coughing, and deep breathing; and time to catheterize if
the patient is unable to void and does not have an
indwelling catheter. Additional orders may request cir- Box 10-3 Guidelines for Taking Telephone Orders
culation checks or monitoring of neurologic status.
• Have the patient’s medical record open to the appropriate
TAKING VERBAL ORDERS page to accept a new physician order. Have a pen ready.
Know the physician’s name.
Taking verbal and telephone orders can be unsafe • Write the order verbatim (word for word) as it is given to
unless carefully performed. The individual giving the you by the physician.
order can misspeak, and the individual receiving the • Read it back to the physician as written; verify spelling of
order can mishear, misunderstand, or misinterpret medications or diagnostic tests. Do this every time with
the order due to numerous factors such as distractions, every physician. Ask the physician to confirm that the
background noise, different pronunciations or accents, order is correct.

or cell phone noise. The Joint Commission discourages • Document the date and time, and indicate “T.O.” for
the use of verbal and telephone orders unless absolutely telephone order with your first initial, last name, and LVN
necessary because they can be unsafe unless specific or LPN.
• Ensure that the physician signs off on the order when
guidelines are followed. If a physician is present on the
making rounds; this must be done within 48 hours in
unit, he should write orders rather than giving verbal most agencies.
orders. If implementation of an order is time critical and • If a telephone order is requested during the hours from
the physician is not available in person, a telephone midnight to 6 a.m., have another person, preferably a
order may be the most appropriate and efficient way to nurse, on an extension to verify the order. Physicians
provide expedient care to the patient. When taking ver- awakened from a sound sleep sometimes do not recall
bal or telephone orders, the nurse is expected to write the exact order. Have the other nurse initial the order, or
the orders in the chart for the physician to sign later. have the other person document the order as he heard it
given and sign it.
• Make an entry in the nurse’s notes describing the cir-
Safety Alert cumstances that prompted a telephone order. Include
Readback the statement that the orders were read back to the phy-
sician and that they were confirmed to be accurate by
The Joint Commission International Center for Patient Safety
the physician when read back.
developed guidelines for accepting and transcribing verbal or
care that must be documented and how often each policies and procedures. The unit leader must insist
must be noted. that all workers adhere to the facility’s written policies
In the long-term care facility, the Minimum Data Set and procedures. Nurses must uphold the standards of
(MDS) must be filled in as accurately as possible for the practice for the area in which they work. Attending to
facility to receive the maximum Medicare or Medicaid patient complaints and showing concern when patients
payment for services rendered. Many facilities use a are upset can help decrease the risk of a disgruntled
special MDS coordinator to ensure that these multiple- patient suing if something goes wrong. It is important
page forms are filled in correctly. Poor documentation to advise your supervisor when a significant problem
may lead to fines imposed by the U.S. Department of has occurred on the unit, along with writing an inci-
Health and Human Services, as well as decreased dent report when there has been cause for a patient or
reimbursement. the patient’s family to be upset with care (see Chapter 3
for a discussion on incident reports). Mediating patient
and family complaints is part of the leadership role.
RISK MANAGEMENT Leadership and management skills develop with
The increasing occurrence of lawsuits against health practice and continued learning. Professional growth
care facilities, physicians, and nurses has focused atten- is an important aspect of an evolving career in nursing.
tion on risk management (management of areas to Each nurse should seek his own direction and pursue
decrease risk of harm to patients, occurrence of law- growth opportunities. Taking classes to improve skills
suits, or excessive damages awards by juries). Risk or finding an experienced nurse to be a mentor (teacher
management practices attempt to prevent unfavorable or coach) are a few examples. After a year of experi-
events or to reduce the agency’s liability. A key risk ence in direct patient care, enough confidence may
management tool is to practice nursing following have been gained to take on greater responsibility in a
accepted professional standards and the agency’s leadership role.
Key Points Additional Learning Resources

• L eadership requires a good grasp of management SG Go to your Study Guide for additional learning activities to help you
techniques, effective communication skills, clinical master this chapter content.
competence, knowledge of the agency’s organizational
structure, and an understanding of yourself and the Go to your Evolve website (http://evolve.elsevier.com/deWit/
effect of your leadership and communication styles on fundamental) for the following FREE learning resources:
others. • Animations
• Laissez-faire leaders offer little, if any, direction; • Answer Guidelines for Think Critically boxes and Critical Thinking
autocratic leaders tightly control team members; and Questions and Activities
democratic leaders frequently consult other staff • Answers and Rationales for Review Questions for the NCLEX®
members and seek participation in decision making. Examination
• Organization of work tasks for the unit is essential; • Glossary with pronunciations in English and Spanish
delegation is necessary to accomplish the workload. • Interactive Review Questions for the NCLEX® Examination and more!
• To safely and effectively delegate, you must know the
capabilities and competencies of the person to whom
you are delegating, understand which tasks you can Review Questions for the NCLEX® Examination
legally delegate, avoid delegating interventions that Choose the best answer for each question.
require professional judgment, and provide feedback.
• Delegation and team leading are beginning leadership 1. Which is an example of democratic leadership?
functions of the LPN/LVN. 1. The manager explains new rules for staff scheduling,
• The charge nurse is responsible for the total nursing care then asks for a vote on how to implement them.
of the patients on the unit during the shift. This position 2. Will, the charge nurse, directs others during an
requires training and experience in administration and emergency situation.
supervision of other personnel. 3. The nurse manager asks advice from her staff nurse
• Computer expertise is necessary for work efficiency; friends as she determines the unit holiday schedule.
computers are becoming essential to patient care. 4. The charge nurse chooses to ignore staff nurses’
• Risk management techniques include following policies failure to follow unit policies and procedures.
and procedures and showing care and concern for
patients.
2. The ideal type of leadership to be demonstrated by the 9. If a patient has a heating pad ordered, but its use is not
nurse managing a patient experiencing a cardiac arrest documented, the insurance company:
is the ________________________________ type of 1. will pay because the physician ordered it.
leadership. (Fill in the blank.) 2. may deny payment because there is no evidence of
use.
3. A good way to handle conflict is to: (Select all that 3. may request further information.
apply.) 4. will request verification from the nurse that the pad
1. speak sternly to those involved. was in use.
2. tell those involved to solve the problem.
3. quickly impose a resolution to the problem. 10. The goal of risk management is to:
4. remain calm and open and listen to all sides. 1. minimize agency liability.
5. focus on the issues, not the personalities involved. 2. minimize the number of risks present in the hospital.
3. minimize the amount of risk the nursing staff is
4. Delegation of a specific task to a UAP requires: (Select allowed to take.
all that apply.) 4. increase nursing competence, thereby decreasing
1. knowledge of the UAP’s competencies. risk of patient injury.
2. understanding of the nurse practice act.
3. direct supervision of the performance of the task. 11. One risk management technique that is known to often
4. documentation that the task was delegated. be effective is to:
5. follow-through by verification that the task was 1. call family members by their given names.
completed. 2. assign the same nurse to care for the patient all
week.
5. Giving constructive criticism should begin with: 3. listen empathetically to complaints or concerns.
1. providing feedback on past performance. 4. tell the patient the physician knows best.
2. stating consequences for the poor performance.
3. acknowledging feelings or expressing empathy.
4. asking how you can help improve performance. Critical Thinking Activities
Read each clinical scenario and discuss the questions with
6. When managing your time during your shift, what
your classmates.
should you do first?
1. Make patient rounds. Scenario A
2. Delegate tasks. You are assigned eight medical-surgical patients on the day
3. Set priorities. shift. You have one nursing assistant who can help you but
4. Create a time schedule. who also is assigned to help another nurse. What tasks
should you consider delegating to this UAP? How would
7. The nurse manager is selecting the next nurse she you verify that the tasks you have delegated have been
wants to promote to the charge nurse position. Which done and done correctly? Would this method help build
candidate would be the best choice? team spirit?
1. Cindy, a young new graduate with a bubbly person-
ality who gets along with everyone Scenario B
2. Elaine, out of school for 9 months, who is articulate You are team leader on one hall. Two of your staff begin to
and highly organized and once held leadership bicker about who should answer the call light that keeps
positions in another field coming on. How would you handle the situation?
3. Gladys, an experienced nurse of 20 years with a

sarcastic disposition, who knows the unit better than Scenario C
anyone A patient needs to have her blood glucose checked before
4. Charles, a traveling nurse, who recently relocated to breakfast. You want the nursing assistant to perform this
the area, and who often ignores physician orders task, and she has been trained to do it. The nursing
that are different from what he thinks is best for the assistant approaches the patient to perform the procedure,
patient and the patient refuses. How would you handle this refusal?
8. According to The Joint Commission, there are safety

concerns about: (Select all that apply.)
1. use of abbreviations.
2. computerized medical records.
3. handoff communication.
4. delegating tasks to UAPs.
5. use of verbal orders.

Fundamental Concepts and Skills For Nursing - (Unit III Communication in Nursing)

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Fundamental Concepts and Skills For Nursing - (Unit III Communication in Nursing)

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Unit III Communication in Nursing

Documentation of Nursing Care 7

sets the standards for documentation. Common types of

Table 7-1 Forms Used for Hospital Documentation

flow sheets, and a written note is added if an abnor-

which tracks variances from the clinical pathway.

ments, treatments, and frequently given care. The spe-

FLOWSHEET 10/10 10/11 Doe, John B.

Activity response tolerated well tolerated well

Hygiene assist bath

Standard prec yes yes

RJK 00:00 FR 08:00 RJK 20:00

IV LINES 11-7 7-3 3-11

Rutken, Frances (FR) RN Kahn, Roland J. (RJK) LPN

FIGURE 7-1 Computer activity flow sheet.

Date Time Problem Nurse’s Notes

FIGURE 7-2 Example of source-oriented (narrative) charting.

Date Time Problem Nurse’s Notes

Date Time Problem Nurse’s Notes

Date Time Problem Nurse’s Notes

FIGURE 7-4 Example of PIE (Problem, Intervention, Evaluation) charting.

PIE Charting FOCUS CHARTING

Date Time Problem Patient Progress

FIGURE 7-5 Example of focus charting.

GUIDELINES FOR USE OF THE NURSING/PHYSICIAN ORDER FLOW SHEET

Specify exactly which parts of assessment should be completed.

documentation system is confidentiality. Every indi-

FIGURE 7-9 Example of part of a patient’s electronic chart.

Cultural Considerations • There is quick communication between depart-

Advantages of computer-assisted documentation a positive impact on patient safety.

Variation Cause Action Taken

FIGURE 7-10 Example of variance charting.

LEGIBILITY AND COMPLETENESS IN CHARTING THE KARDEX

FIGURE 7-11 Example of home care agency charting.

Date/Time Licensed Nurses Progress Notes

FIGURE 7-12 Example of long-term care facility charting.

Box 7-2 Guidelines for Charting About a Sign or a Symptom

Box 7-3 Types of Information to Be Documented

• Death • Mental state and mood • Teaching

Box 7-4 General Guidelines for Charting

• Clearly identify care given by another health care team member.

2100 9:00 3:00 1500

Get Ready for the NCLEX® Examination!

Key Points • C omputer charting is expensive to institute but saves

assisted charting, and (6) case management system

4. One characteristic differentiating source-oriented Critical Thinking Activities

Communication and the

empathy (ĔM-pă-thē, p. 107) therapeutic (thĕr-ă-PYŪ-tĭk, p. 103)

THE COMMUNICATION PROCESS spoken or written. Nonverbal communication, also

Good communication requires active listening

“Help me move you up in bed by

You can learn about patients by observing nonver- Cultural Considerations

cultural values, education, familiarity with the topic, Active Listening

unpleasant a patient says when upset or frightened.

COMMUNICATION SKILLS Elder Care Points

centered care, with the patient as the focus, is essential

ally the approach, “We’ll come back to that later, but

THERAPEUTIC COMMUNICATION TECHNIQUES RESTATING

Table 8-1 Therapeutic Communication Techniques

recognize that you are repeatedly saying her words TOUCH

patient in looking at alternative solutions to a problem.

indicated that you have a choice between undergoing

Table 8-2 Blocks to Effective Communication

Table 7-1 Forms Used for Hospital Documentation

Cultural Considerations • There is quick communication between depart-

Box 7-2 Guidelines for Charting About a Sign or a Symptom

Box 7-3 Types of Information to Be Documented

• Death • Mental state and mood • Teaching

Box 7-4 General Guidelines for Charting

• Clearly identify care given by another health care team member.

Key Points • C omputer charting is expensive to institute but saves

4. One characteristic differentiating source-oriented Critical Thinking Activities

Table 8-1 Therapeutic Communication Techniques

Table 8-2 Blocks to Effective Communication

Box 9-1 Topics for Patient Teaching Think Critically

• Family support and availability

3. Gladys, an experienced nurse of 20 years with a

8. According to The Joint Commission, there are safety