COOU Nursing Foundation Communication Notes PDF

#### COOU. 200LEVEL. First semester FOUNDATION OF NURSING 1 NSC201 Unit IV **Tools in Nursing** **Communication in Nursing** **Definition: communication is inter**action between people. It is a process of sending and receiving information.communication must be encoded and decoded for proper unde...

#### COOU. 200LEVEL. First semester FOUNDATION OF NURSING 1 NSC201 Unit IV **Tools in Nursing** **Communication in Nursing** **Definition: communication is inter**action between people. It is a process of sending and receiving information.communication must be encoded and decoded for proper understanding..The elements of communication include Sender\-\-\-\--channel\-\-\--message\-\-\-\--receiver.\-\--Feedback. **Levels of communication** - Interpersonal and interpersona**l** - Small group - Public communication.  Communication is the active process of exchanging information and ideas between individuals or groups, involving both understanding and expression. **Types** **verbal**, communication involves these Principles: Speaking and intonations, simplicity, clarity and brevity, timing and relevance, adaptability, credibility and humour. **written**, clarity, focused to the point. **Non-verbal** : personal appearance, posture, gait,facial expression and gestures, eye contact, touch **Purpose of communication in Nursing** - - - - - - - - **Importance of communication in Nursing** Communication is an essential part of all aspects of nursing, including prevention, treatment, rehabilitation, and education. The importance of good communication in nursing cannot be overstated. 1. Effective communication in nursing is essential for creating a positive patient experience and ensuring patient safety. 2. Provides information for the patient and others 3\. Communicating effectively with patients and their families engages them in their own health care and helps them take important information on board. It helps patients recover in the shortest possible time frame and avoid readmission. 4\. Nurses communicate with colleagues, and other health team members verbally and in writing. 5\. Research has shown that effective communication in nursing provides job satisfaction and morale. 6\. communication in nursing is part of the reason for reduced stress. **Effective communication Skills.** Active listening Respect Understanding of culture, language and personal attitude Communication **skills, clarity, concise.** **Listening** **Compassion** **The seven C's of communication** 1. Clear. 2. Concise. 3. Concrete. 4. Correct. 5. Coherent. 6. Complete 7. Courteous This is ongoing interaction between people that involve the mutual fulfillment of both parties\' needs. A key characteristic of interpersonal relationships is that they involve **self-disclosure**, or the sharing of personal and intimate information about oneself. **SOCIAL AND PROFESSIONAL** **RELATIONSHIP:** **In nursing** profession the following relationship are considered to be significant  Nurse-Patient  Nurse-Patient's family  Nurse-Physician  Nurse-Administrator  Nurse-Supervisor  Nurse-Educators  Nurse-Nurse  Nurse-Nursing student  Nurse-Other health care professiona Elements of interpersonal relationships Trust, caring, Rapport, Genuineness, Respect and empathy. There are **three** **types** of interpersonal relationships I. Social II. Intimate III. Therapeutic 1. Pre interaction :Obtaining available information about the patient from chart and other health team members. b\) Initial assessment of patient. c\) Plan first meeting with the patient. 2\. Orientation a\) Establishment of trust and rapport. b\) Maintaing privacy. d\) Formulate nursing diagnosis. 3.Working phase a\) Maintaining the trust and rapport that was established during the orientation phase. b)Problem solving approach. c\) Continuous evaluation of progress towards the goal attainment. 4\. Termination a\) The mutually agreed goals may have been reached b\) Patient may be discharged from the hospital. c\) In the case of student nurse it may be the end of clinical rotation **Documenting and Reporting** ----------------------------- Quality client care relies heavily on efficient communication among healthcare professionals. Typically, health personnel engage in communication via discussions, reports, and records to ensure seamless coordination and collaboration. A **discussion** entails an informal verbal exchange among two or more healthcare personnel aimed at identifying or resolving a problem by establishing strategies. A **report** comprises oral, written, or computer-mediated communication designed to convey information to others. For example, nurses routinely provide updates on clients after a hospital shift. A **record**, also referred to as a **chart** or **client record**, serves as a formal, legal document offering evidence of a client's care, whether in written or computer-based format. Despite variations in documentation systems and forms across healthcare organizations, client records typically contain similar information. The act of recording information in a client record is known as **charting**, **documenting**, or **recording**, reflecting the standardized approach to documentation in healthcare settings. **Documentation** is anything written or printed that is relied on as a record of proof for authorized persons. These are required in nursing for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a **nurse**. ### **Purposes of Documenting and Reporting** Documenting and reporting in nursing serve multifaceted purposes crucial for effective healthcare delivery and accountability. **1. Communication.** Through documentation and reporting, nurses facilitate seamless communication among healthcare professionals, ensuring the continuity of care and promoting patient safety.. **2. Planning Client Care.** Detailed documentation aids in the formulation and execution of individualized care plans, providing a comprehensive overview of patient needs, interventions, and outcomes. **3. Auditing Health Agencies.** Accurate documentation enables health agencies to assess compliance with regulatory standards, identify areas for improvement, and ensure the provision of high-quality care. **4. Research.** Documented data serves as valuable resources for research endeavors, contributing to evidence-based practice and advancements in nursing knowledge and patient care. **5. Education.** Documentation and reporting provide valuable learning materials for nursing students and healthcare professionals, offering real-life case studies and examples to enhance understanding and skill development. **6. Reimbursement.** Thorough documentation supports reimbursement processes by accurately reflecting the care provided to patients, ensuring proper billing and reimbursement for healthcare services. **7. Legal Documentation.** Documentation serves as legal evidence of the care provided, protecting both patients and healthcare providers in case of litigation or disputes. **8. Health Care Analysis.** Aggregated data from documentation and reporting systems allow for the analysis of healthcare trends, outcomes, and performance metrics, facilitating continuous quality improvement initiatives and informed decision. **Documentation System Methods** -------------------------------- Effective documentation systems are integral to ensuring accurate communication, maintaining legal records, and supporting clinical decision-making. ### **1. Source--Oriented Medical Record** A source-oriented medical record (SOMR) is a traditional format for maintaining patient information, where each department or healthcare provider documents their observations, interventions, and outcomes in designated sections of the patient's ch ### **2. Problem--Oriented Medical Record (POMR)** The Problem-Oriented Medical Record (POMR), established by Dr. Lawrence Weed in the 1960s, represents a significant shift in medical **Data Organization by Patient Problems. **Unlike traditional source-oriented records, where information is compartmentalized by department (e.g., [nursing notes](https://nurseslabs.com/focus-charting-f-dar-how-to/), physician orders), POMR arranges all data based on the specific problems a patient is experiencing. This organization begins with a comprehensive problem list, which is the cornerstone of the POMR system. Each problem listed is then documented in a structured format, typically including: #### The Four (4) Basic Components **1**. **Database. **A complete history and physical examination, along with initial lab results and diagnostic tests, provide a baseline of patient information. **2. Problem List.** Derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved. **3. Plan of Care. **For each identified problem, initial plans are developed and documented. These plans are divided into three categories: diagnostic (further tests needed), therapeutic (treatment plans), and patient education (information provided to the patient). **4. Progress Notes.** Using the SOAP (Subjective, Objective, Assessment, Plan) format, progress notes detail ongoing care and updates for each problem. This format ensures consistency and thoroughness in documenting patient care. **Example: SOAP Format or SOAPIE and SOAPIER** The SOAP, SOAPIE, and SOAPIER formats provide structured and systematic approaches to documenting patient care. By following these formats, healthcare providers can ensure thorough and consistent documentation, facilitating effective communication, continuity of care, and informed decision-making. Each additional component (Intervention, Evaluation, and Revision) enhances the depth and adaptability of the documentation, allowing for a dynamic and responsive approach to patient management. - - - - - - - - ##### SOAP Format The SOAP format is a structured method used for documenting patient care in the Problem-Oriented Medical Record (POMR) system. It provides a clear and systematic way to record clinical information, ensuring comprehensive and consistent documentation. **S -- Subjective Data:** - - **O -- Objective Data:** - - **A -- Assessment:** - - **P -- Plan:** - - ##### SOAPIE Format The SOAPIE format extends the SOAP method by adding two additional components: Intervention and Evaluation. **I -- Intervention:** - - **E -- Evaluation:** - - Nursing Handover ================ Handover is an essential part of any clinicial job. Effective handover in nursing is accurate, methodical and consistent, leading to improved continuity of care, better outcomes for patients and a reduced work burden for staff and the wider healthcare organisation. Handover in healthcare is the process where information is shared between nurses who are responsible for the care of a patient. Handover commonly takes place at the beginning and end of shifts and whenever a patient moves to another team. The information includes the patient's history, current condition, and future treatment plans and other pertinent details. A good nursing handover is one that is: 1\. Focused 2\. Concise 3\. Timely 4\. Complete 5\. Organised It ensures that all healthcare professionals who are responsible for the care of a patient are aware of the patient's condition and treatment plans. ### **The dangers of inadequate nursing** handover 1. Causes delays in patient care, patient discharge and increases the number of preventable medical errors. 2. Lack of immediate update. This communication can only happen smoothly and promptly if the information was handed. 3. Poor tracking of patient needs and updates. 4. Handing over using two systems or mediums is a recipe for disaster. Safety and efficiency can be protected by utilising one method and if possible one medium (i.e. digital vs paper). This makes it easier for information to be communicated to the new team or shift without risking important facts and updates being missed. ### **The Benefits of handover in nursing** While handovers between staff and teams take place hundreds of times a day in hospitals they represent a high risk to patient. A good and effective handover is key 1. It maintains integrity of information and patient safety. This includes not only on the ward handover between day and night shift but also between ward teams and other institutions. 3\. There is a wide ranging impact not only for patients but at a staff and organisational level as well. These include but are not limited to: - Reducing avoidable harm - Reducing patient history repetition - Better support for doctor's clinical decision making - Reassurance for relatives with the latest, relevant information - Reduce stress - Reduce time reviewing patient records - Maintain consistent, accurate records and audit trail ### **Barriers to effective Nursing Handover** ### **\*Improper** task -- transfer of patient information makes handover complex. This inherent complexity is where the danger of incomplete or omitted information arises. ### **\*The** shifting of responsibility to another team or team member. The process therefore relies on the communication methods of both parties, their individual work cultures and differing workloads and priorities. \*Casual or poorly organised handover. Each variable will not only dictate to an extent both the efficiency and the effectiveness of handover, but also the level of risk to patient safety for the upcoming shift. These barriers can be overcome somewhat with an approach that is both supportive and consistent in method, modality and culture. This means both parties are benefiting from modern methods of information recording and transmission. Rather than scribbling on loose bits of paper or reading smudges on a whiteboard, digital clinical systems can be used to reliably log and transfer information when required. \*This also means engaging in the same routine and process, at a known setting. Setting time and private space reduces interruptions, attending staff delays and provides the base framework to operate from. \*Routine and process ensures that despite differences in work culture, priorities and workload helps the input and output of each meeting to remains consistent. \*We know that without a focus on good handover, incomplete information, distractions, and errors in communication during the nurse handover are the principal causes of adverse events, such as medication errors, prolonged hospital stays with unnecessary diagnostic tests, and patient dissatisfaction**.** ### **What are the 5 key principles of clinical** handover? The five key principles of clinical handover are: 1\. Focused 2\. Concise 3\. Timely 4\. Complete 5\. Organised However these are clearly the basics concepts of handover. For it to be *effective* there needs to be boundaries set in place to ensure consistency. Remember that effective handover is easiest to achieve when it is: - Consistent -- method, process and outcome - Private -- protecting patient confidentiality and reducing distraction - Understood -- parties know expected inputs and outputs. **Nursing process** Nursing process is a systematic , patient -- centered , goal -- oriented method of caring to provide a frame work for nursing practice. **Objectives of N P (Nursing process )** The steps of the nursing process are not separated items , but rather are parts of whole used to ; -Identify needs of the patient. -To establish priorities of care. -To maximize strengths. -To resolve actual & or potential patient problem. -To apply health promotion that is possible for each patient Documenting the nursing process is the ability to record communicated nursing skills in a , Accurately, Concisely,Timely,& Relevant way and To provides the member of the caregiver a complete picture of the patient health. **Phases** The six phases of the nursing process are 1- assessment, 2- diagnosis, 3-out come identification, 4- planning, 5- implementation, 6- and evaluation. **Assessment** Assessment ; is the systematic & continuous collection , validation & communication of patient data -Data base ; includes all patient information , collected by the health care professionals to enables an effective plan of care to be implemented for the patient. **Sources of the data;** -patient , is the primary source of information. -family &significant others , friends. -\* patient record , records from members of health care , provide essential information related to him. -Medical history ,physical examination ,& progress notes. -laboratory test &other health professions. **TYPES OF ASSESSMENT** ; -Initial assessment ; is performed shortly after patient admission to a health agency or hospital. -Focused assessment ; the nurse gathers data about a specific problem that has already been identified. -Emergency assessment , the nurse performs this type of assessment on a physiological or psychological crisis to identify the life -- threatening problems. -Time -- lapsed assessment , this assessment done to compare a patients current status to the base line data obtained earlier. **Assessment skills** 1- Observation 2- Interviewing \- directive interview nondirective interview 3- Physical examination techniques: -Inspection \- Palpation -Percussion -Auscultation Assessment Activities- \*Identify assessment priorities determined by the purpose of the assessment and the patient condition. \*Organize or cluster the data to ensure systematic collect \*Establish the data base by; -nursing history -nursing examination - review of patient record & nursing literature. -patient consultation,& health care personal \*Continuously update the database \*Validate the data. \*communicate the data. **Nursing Diagnosis** Diagnosing ;(patient problem), the 2nd step of nursing process. Is a clinical judgment about individual , family or community response to actual or potential health problem. It provides the bases for selection of nursing intervention. **Activities of nursing diagnosis;** \*Interpret & analyze patient data \*Identify patient strength and health problem \*Formulate and validate nursing diagnosis \*Develop a prioritized list of nursing diagnosis \*Detect & refer signs and symptoms that may indicate a problem beyond the nurses experience. **Parts of Nursing Diagnosis ;** \*Problem ; statement that describe the health problem of the patient clearly & concisely. \*Etiology ; The reason (etiology)that identifies the physiological , psychological ,social ,spiritual & environmental factors related to the problem. -Defining characteristics (signs or symptoms ). The subjective & objective data that signal the existence of the problem. Example;. characteristics etiology problem Deficient fluid volume Dry skin Diarrhea, dryness of the mouth. **Differentiating Nursing Diagnosis versus Medical Diagnosis** Nursing Medical Diagnosis 1. focus on unhealthy responses to health and illness. \- identify diseases 2\. Describe problems treated by nurses within the scope of independent nursing practice. \- describe problems for which the physician directs the primary treatment. 3\. May change from day to day as the patient's responses change \- remains the same for as long as the disease is present **Types OF Nursing diagnosis** 1-Actual Nursing Diagnosis; represent a problem that has been validated by the presence of its characteristics ,eample, impaired physical mobility , fatigue ,ineffective breathing pattern. 2-Risk NURSING Diagnosis ; its a clinical judgment that an individual , family , or community is more vulnerable (able) to develop the problem.example risk for deficient fluid volume , 3-Possible Nursing Diagnosis ; are statements describing a suspected problem.ex ,chronic low self --esteem. 4-Wellness Diagnosis ; ITS a clinical judgment about individual , group , or community in transition from specific level of wellness to a higher level.ex ,Readiness for enhanced health maintenance ,or Readiness for enhanced self-esteem. 5-Syndrome nursing Diagnosis ; a cluster of an actual or risk nursing diagnosis suspected to be present according to certain events. **Nursing Planning** The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client's plan of care. **Activities of planning phase (or step)** Identify expected patient outcome. -Select evidence- based nursing intervention. -Communicate the plan of care. Stages of planning ; \*Initial planning ; is developed by the nurse , who performs the admission nursing history and the physical assessment. \*Ongoing planning ; is carried by the nurse to keep the plan up date , by analyzing data to make plan more accurate. \*Discharge planning ; is best carried out by the nurse ,who has worked most closely with patient and family **The four critical elements of planning include:** Establishing priorities Setting goals and developing expected outcomes (outcome identification) Planning nursing interventions (with collaboration and consultation as needed) Documenting **Implementation** : Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. **Types of interventions** -Direct interventions: actions performed through interaction with clients. Indirect interventions: actions performed away from the client, on behalf of a client or group of clients. The nursing care plan consists of three components:- -Expected outcomes -Client problems (nursing Diagnosis) -Interventions **Types of interventions ** -Dependent -Independent -Collaborative Evaluation The last phase of the nursing process, follows intervention of the plan of care, it's the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. **Evaluating**: \*Measure how well the patient has achieved desired -Final phase of nursing process -Occurs whenever nurse interacts with client Determining status of outcomes -Systematic & ongoing outcomes \*Identify factors contributing to the patient\'s success or failure \*Modify the plan of care, if indicated. Three possible outcomes of evaluation -Outcomes not met -- continue plan as written -Outcomes not met -- modify the plan -Outcomes met -- terminate the plan **Factors affecting outcome attainment:-** 1- facilitators 2-barriers Evaluating compliance: 1-performance appraisal 2-quality assurance Relationship of Evaluation to Nursing Process **\*\*Use nursing process for any identified nursing diagnosis\*\***