Nursing: A Concept-Based Approach to Learning Module 38 Communication PDF

Nursing: A Concept-Based Approach to Learning Volume Two, Fourth Edition Module 38 Communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved  The Concep...

Nursing: A Concept-Based Approach to Learning Volume Two, Fourth Edition Module 38 Communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved  The Concept of Communication Communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Concept Learning Outcomes 38.1 Analyze the process of communication. 38.2 Differentiate the various forms of communication. 38.3 Outline the relationship between communications and other concepts. 38.4 Analyze the factors that influence the communication process. 38.5 Analyze barriers to effective communication. 38.6 Analyze the various types of communicators. 38.7 Summarize the attributes of a nurse who uses assertive communication. 38.8 Differentiate considerations related to communication throughout the lifespan. 38.9 Analyze the nursing process as it relates to a patient with impaired verbal communication. Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved The Concept of Communication Poor communication can result in poor health outcomes Communication: any means of exchanging information or feelings between two or more individuals All communication has the intent of eliciting a response Two main purposes of communication – To influence others to respond – To obtain information Four specific types of communication are explored Therapeutic communication essential for healthy nurse–patient relationship Documentation is primary form of written communication – Reporting through handoff is process of nurse-to-nurse communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Modes of Communication Typically occurs through either verbal or nonverbal Methods – Verbal: use of written or spoken words – Nonverbal: contrast, gestures, facial expressions, touch Electronic communication – Mode of communication that evolves with technology – Electronic communication used in the workplace is email, whereas social networking and text messaging – Forms of electronic communication ▪ Patients ▪ Families ▪ Other healthcare professionals Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Verbal Communication Is primarily a conscious and purposeful activity Considerations: Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Nonverbal Communication Nonverbal communication Includes – Gestures – Facial expressions – Use of touch – Body position and movement – Physical appearance Can express more about an individual’s feelings Has the ability to either support or contradict Must be able to interpret feeling/emotion patient is expressing nonverbally Requires a systematic assessment that includes – Mental status – Gestures and facial expressions – Posture and gait Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Electronic Communication Advantages Disadvantages Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Written Communication A form of verbal communication By hearing tone of voice and seeing body language can context be relayed Common form used notes documented in the medical record related to a patient’s status and assessments Nurse managers use written communication in ways – Employee evaluations – Policies and procedures – Colleagues – Nursing staff May be days before the intended recipient reads the information Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Concepts Related to Communication Advocacy Comfort Grief and Loss Intracranial Regulation Mood and Affect Oxygenation Safety Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Factors Influencing the Communication Process Factor Notes Development Gender Values and Perceptions Roles and Relationships Environment Congruence Interpersonal Attitudes Personal Space Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Factors Influencing the Communication Process (4 of 10) Personal space – Defined as distance people prefer to keep between themselves and others during social, family, or work related Interactions – Proxemics: ❑Refers to the amount of space individuals are comfortable putting ❑Intimate distance ❑Personal distance: ❑ Social Distance ❑ Public Distance Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Barriers to Communication (1 of 2) Stereotyping – Categorizes patients, negates their individuality Agreeing and disagreeing – Imply that patient is either right or wrong and nurse is in position to judge Being defensive – Implies that patient has no right to complain Challenging – Important not to make patient prove statement or point of view Probing – Asking for information out of curiosity rather than to assist patient Testing – Asking questions that make patient admit to something Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Barriers to Communication (2 of 2) Rejecting – Refusing to discuss certain topics with patient Changing topics and subjects – Directing communication to areas of self-interest rather than patient’s concerns Unwarranted or false reassurance – Blocks patient’s fears, feelings, other thoughts Passing judgment – Implies that patient ought to think as nurse does, fosters patient dependence Giving common advice – Denies patient’s right to be equal partner Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Types of Communicators Aggressive – Focus on own needs, become impatient when needs not met – Often perceived as personal attack by recipient Passive – Focus on needs of others, often denying own power → frustration – Rights violations may occur Assertive – Declare and affirm opinions – Respect rights of others to communicate assertively – Most productive communication with others – Stand up for themselves while remaining open to ideas and respecting Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Assertive Communication Direct, nonconfrontational expression of all ideas Promotes rights of nurse or patient while respecting others’ rights to different outlook Nonjudgmental, non-blaming, increases likelihood of win–win result Characteristics of assertive communicators – Freedom to express selves – Awareness of own rights – Self-control over strong emotions – Professional, advocate for patient – Express own opinions, open to others’ points of view – Use relaxed body language, well-modulated tone of voice – Able to receive feedback, considers positive, negative perspectives of evaluator ▪ May not believe everything said but will not become defensive or angry – Considers value of positive feedback for later application to similar situations Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Benefits of Assertive Communication Improves communication Reduces stress De-escalates conflict Improves outcomes Reduces likelihood of angry encounters Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Techniques for Assertive Communication "I" statements Fogging – Finding even small area of agreement, building from there Negative assertion – Agreeing with criticism without becoming upset or angry, focusing on positive Repetition Confidence Managing nonverbal communication Thinking before speaking Avoiding apologizing whenever possible Performing a post-conversation evaluation Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (1 of 8) Infants – Communicate nonverbally ▪ Often in response to bodily sensations ▪ Not necessarily conscious effort to be expressive – Perceptions related to sensory stimuli – Two types of nonverbal cues ▪ Engagement cues: smiling, babbling, opening hands ▪ Disengagement cues: crawling away, crying, lip compression – Nurses can become familiar with infants’ expressive message to communicate more effectively with them Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (2 of 8) Toddlers – Gaining skills in expressive, receptive language – Need time to finish verbalizing thoughts without interruption – Adults should provide simple responses to questions – One-step directions to accommodate short attention spans ▪ Begin following two-step directions around age 4 years – Helpful to draw pictures, use pictures and photos to communicate Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (3 of 8) School-age children – Important to give them opportunities to be expressive – Listen openly, respond honestly, using words and concepts they understand – Talk at their eye level – Include child in conversation, take part in their healthcare – Play allows them to use other symbols to express selves, not just words – Even nonverbal children can use drawing, painting, other art forms – Storytelling can help child safely express emotions – Reading books or watching movies, or videos with theme similar to child’s condition, then discussing meaning, characters, feelings generated by book can assist communication about condition, child’s experiences with it – Older children can use writing to reflect on situation, give it meaning, gain sense of control Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (4 of 8) Adolescents – Have ability to think abstractly, make decisions about own healthcare – Focuses on development of effective communication skills, feel strong need to share thoughts, facts, feelings with others – Takes time to build rapport – Nurses should use active listening, project nonjudgmental attitude and nonreactive behaviors ▪ Even when adolescent makes disturbing comments – Very sensitive to feelings of judgment ▪ Essential to remain open minded when communicating with them – Prefer expectations to be clearly explained – Appreciate praise Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (5 of 8) Adults – Young and middle-aged adults are at the peak of communication abilities – Wide range of communication abilities based on differences ▪ Cognitive abilities ▪ Education levels ▪ Socioeconomic levels ▪ Exposure to professional, work environments ▪ Health literacy – Young adults may still have some adolescent communication patterns – In upper middle age, may begin to have physical, cognitive problems seen in older adults – Nurses should identify any barriers to communication and plan accordingly Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (6 of 8) Pregnant women – Effective therapeutic communication essential to patient safety, comfort – Nurse should determine family’s cultural values about birth – Engage in shared decision making – Listen to patient as well as providing support Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (7 of 8) Older adults – Physical or cognitive problems may necessitate nursing interventions to improve communication ▪ Sensory deficits ▪ Cognitive impairment ▪ Neurologic deficits ▪ Psychosocial problems – Nursing interventions to improve communication ▪ Ensuring that patient has, is using assistive devices, glasses, and hearing aids as appropriate ▪ Using communication aids – Paper and pencil, communication boards, tablets or computers, pictures ▪ Referral to appropriate services, resources Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (8 of 8) Older adults – Effective communication strategies ▪ Keep environmental distractions to minimum ▪ Speak in short, simple sentences –One subject at a time ▪ Avoid elderspeak ▪ Always face patient when speaking ▪ Include family, friends in conversation ▪ Believe nonverbal communication when incongruence between verbal, nonverbal ▪ Careful attention to patient’s feelings ▪ Find out what is important to patient, try to maintain these things –Example: bedtime rituals Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Nursing Process Communication is essential to – Assessing – Monitoring – Evaluating – Patients Providing direct patient care and education Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Assessment (1 of 5) Evaluate patient’s communication style Appraise any language or communication barriers – Keep cultural values, practice in mind Language deficits – Needs to assess the ability to communicate both verbally and Nonverbally – Impairment that affects ability to communicate Sensory deficits – Note the presence of a hearing aid, medical alert bracelet, necklace, or tag indicating hearing loss – For patients who use hearing aids, confirm that the hearing aid is turned on and functioning – Observe if the patient is trying to see your face to read lips – Observe if the patient is trying to use the hands to communicate sign language – Evaluate feedback to validate that effective communication is taking place Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Assessment (2 of 5) Cognitive impairments – Disorders that impair cognitive functioning can affect patient’s ability to use, understand language – Some medications can impair speech – Some patients may lose ▪ The ability to find or name words ▪ May experience impaired articulation ▪ May completely lose their ability to speak – Assessment of patient’s ability respond to verbal communication includes ▪ Does the patient speak fluently or hesitate when speaking ▪ Does the patient use words in the correct manner, putting words in the right order and using them appropriately to their meaning ▪ Can the patient understand instructions, as evidenced by following directions ▪ Can the patient repeat words or phrases when instructed to do so Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Assessment (3 of 5) Other impairments – Can impair speaking ability and speech patterns ▪ Extreme shortness of breath ▪ Airway obstruction ▪ Structural defects of the oral and nasal cavities – Paralysis of the upper extremities requires ▪ Assessment of the patient’s ability to – Blink – Nod – Point – Squeeze a hand Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Assessment (4 of 5) Style of communication – When assessing communication style should consider both verbal and nonverbal communication – Ability to communicate can be influenced by ▪ Cognitive impairment ▪ Psychosis ▪ Delirium or severe depression – Altered thought processes that may present as a result of these illnesses include ▪ Repeated verbalization of the same words or phrases ▪ Talking about people or things that are not present ▪ Flight of ideas Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Assessment (5 of 5) Verbal communication – Indicators to consider include ▪ Pattern of communication: Is the patient’s speech slow, rapid, spontaneous or hesitant, quiet or overly loud or aggressive, or evasive ▪ Vocabulary and any deviations from normal vocabulary, acute illness or extreme distress may cause patients to use language they may not normally use ▪ Changes in articulation of words: pronounce a specific sound, lack of clarity, speak in sentences, loose association, flight of ideas ▪ Refusal or lack of ability to speak Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Diagnosis Nursing diagnosis related to communication may be made – Difficulty with communication ▪ Receptive communication ▪ Expressive communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Planning Nurse works with patient to plan strategies to ensure successful communication Goals may include that patient will – Patient will have an effective method – Patient will maximize the ability to understand and be understood by others Nurse should facilitate access to any assistive communication devices Should be noted in the patient’s electronic health record and made available Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Implementation (1 of 5) Manipulate the environment – Quiet environment – Adequate light – Successful nurse–patient communication – Should acknowledge and praise the patient’s attempts at communication and assist family members Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Implementation (2 of 5) Provide support – Essential to supporting patients ▪ Providing encouragement ▪ Nonverbal reassurance – Nurse must make the patient aware – Stop frequently during conversation to determine – Open-ended questions will assist nurse to obtain more accurate information Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Implementation (3 of 5) Employ Measures to Enhance Communication – To facilitate communication ▪ First needs to assess how the patient best receives information ▪ By listening, looking, or reading ▪ Through touch ▪ Through using an interpreter – Nurse should use words with simple ▪ Concrete meanings and stay on topic Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Implementation (4 of 5) Avoid potential cultural barriers to communication – Nurse should remember several strategies ▪ Avoid slang, buzzwords, medicalese ▪ Avoid words that may impede the communication process ▪ Avoid speaking too slowly ▪ Use open-ended questions and rephrase them – Select gestures with care ▪ May have different meanings in different cultures ▪ Validate words and gestures with each patient – Use interpreters when necessary ▪ Use of family members can raise confidentiality, privacy issues Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Implementation (5 of 5) Avoid potential cultural barriers to communication – Strategies for use in caring for patients from a different culture ▪ Use proper form of address for patient’s culture ▪ Know how individuals in patient’s culture greet one another ▪ Be aware of what a smile means in patient’s culture ▪ Remember that not all gestures have universal meaning Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Evaluation To determine whether patient outcomes – Should listen actively and observe nonverbal cues Overall patient outcome for individuals verbal communication is reduction or resolution Outcomes of care for patient impaired communication may include – Patient communicates effectively that needs are being met – Patient demonstrated appropriate use of the inhaler – Patient communicates effectively – Patient is expressing reduced frustration, fear or anxiety – Patient uses available resources appropriately Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved  Exemplar 38.B Therapeutic Communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Exemplar Learning Outcomes 38.B Analyze the interactive process of therapeutic communication. ▪ Summarize the various techniques used by nurses to support patients. ▪ Outline the phases of the therapeutic relationship. ▪ Explain ways that nurses can develop therapeutic relationships with patients. ▪ Differentiate considerations related to therapeutic communication throughout the lifespan. Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Overview (1 of 2) Therapeutic communication: interactive process between nurse, patient Therapeutic relationship: caring relationship between nurse and patient based on – Mutual trust and respect – Sensitivity – Nurturing Therapeutic communication helps patient – Overcome temporary stress – Get along with other people – Adjust to situations that cannot be changed – Overcome psychologic blocks that hinder self-realization Therapeutic communication promotes understanding, helps to establish constructive relationship between nurse and patient Therapeutic relationship has specific purpose: helping patient achieve health goals Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Overview (2 of 2) In therapeutic communication, nurse responds not only to content of patient’s message but also to patient’s expressed feelings, nonverbal cues – Can help patient focus on feelings – Can help patient deal with feelings before coping with certain events Nurse should help patient explore feelings, alternatives but not participate in patient’s decision making Many times, patients need time to process emotions before they can participate in healthcare interventions, including care planning Nurses should not participate in decision-making process with patients or their families Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Therapeutic Communication Techniques Rooted in acceptance of patient’s point of view – Nontherapeutic communication puts barriers in way of open communication Relies on active listening, continuous confirmation that both nurse, patient being understood Nurse takes time to answer questions, encourage patients to satisfy curiosity Nurse focuses on most important issues, summarizes important points – Nontherapeutic communication includes irrelevant personal questions, sharing unnecessary personal information Nurse must embrace techniques, adapt them to each situation to improve communication with patients Use a holistic approach to communicating with patients in each situation Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Empathizing More than active listening Empathy: process in which one can put oneself in someone else’s situation Nurse must be able to – Understand, acknowledge the ideas the patient is expressing or feels are important – Accept, respect the patient’s feelings as valid for patient ▪ Even if nurse would feel differently in similar circumstances Allows nurse to connect with patients Validates importance of patient’s message to nurse Not synonymous with sympathy – Empathy contains no condolence, agreement, or pity – Focuses on patient’s feelings, not nurse’s Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Active Listening Perhaps the most important technique in therapeutic communication Also called attentive listening or mindful listening Involves listening with multiple senses, to listening only with the ear Paying attention to the patient’s: verbal and nonverbal messages – Noting congruency between them Nurse maintains focus on patient’s needs while exhibiting attitude of caring Nurse not to interrupt or react too quickly Looking for key themes in patient’s message Nurse should ask questions to obtain additional or clarify information – To ensure nurse fully understands what patient is trying to convey Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Physical Attending Describes nonverbal language that expresses attention to another person – Nurse is present, attending to patient includes looking Nurse maintains – Relaxed posture with natural gestures – Speaking to a patient from the door – Maintaining good eye contact Therapeutic communication techniques facilitate communication – Focus on patient’s concerns Touch can also be used as a part of therapeutic communication – But nurses are advised to use it with caution, intention ▪ Different cultures may view use of touch differently ▪ Patients with history of sexual abuse, trauma, personality disorders may misinterpret Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Using Silence Uses of silence, sitting or walking quietly with patient – Encourages patient to communicate – Allows patient time to think about what has been said, make connections – Allows patient time to collect thoughts – Allows patient time to consider alternatives Maintain open posture or questioning look Uncomfortable silence should be broken Nurse who is silent out of discomfort, lack of knowledge should seek guidance, look for personal, professional areas needing growth Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Reflecting (1 of 2) Actively acknowledging what nurse sees, hears from patients Repeating the patient’s verbal or nonverbal message for patient’s benefit Reflecting content – Repeats patient’s statement ▪ Allows patient to hear, reflect on what patient said – May be misused, overused – Use judiciously Reflecting feelings – Verbalizes implied feelings in patient’s comment – Attempting to identify latent or connotative meanings – Encourages patient to make additional clarifying statements Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Imparting Information Helps patient by supplying additional data for consideration Inappropriate to withhold information when patient asks information-seeking question Must be mindful not to cross line between information and advice Do not give information as a way of avoiding conflict Avoid giving patient personal, social information – Must give patient nurse’s name, title, position – New nurses must be cautioned to resist temptation to divulge inappropriate information Patient participation in decision making begins with patient taking in, understanding information about patient’s condition Patient empowerment → positive physical and mental health outcomes Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Avoiding Self-Disclosure Techniques for deflecting requests for self-disclosure – Honesty – Benign curiosity – Refocusing – Interpretation – Seeking clarification – Responding with feedback and limit setting Use techniques within context of therapeutic relationship Maintain a patient focus during communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Clarifying Attempt to understand basic nature of patient’s statement Ask patient to give an example – Allows patient to clarify meaning of the communication – Helps the nurse understand the intended message May be needed because of language patient uses May be needed when nurse is uncertain of adequate interpretation of what patient is trying to convey Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Paraphrasing Nurse restates patient’s statements in own words Nurse can test own understanding of what patient is trying to communicate Reflective in nature – Lets patient know what nurse heard, how nurse understands what is being discussed Allows patient to clarify content of message or feelings Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Checking Perceptions Sharing how nurse perceived and heard information – Important to ask patient to verify perception Conveys that nurse wants to understand what patient is communicating Gives patient opportunity to correct inaccurate perceptions Allows nurse to avoid actions based on false assumptions about patient Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Questioning Very direct way of speaking with patients Useful when nurse seeks specific information Open-ended questions – Elicit more information – Allow nurse to focus on topic while allowing patient freedom with responses Closed questions – Limit patients’ responses to yes or no, limit therapeutic exploration – Useful for guiding patient whose thinking is disorganized “Why” questions less helpful than open-ended questions – Require higher level of insight by patient – Rarely lead to fuller understanding by nurse Must be careful not to ask questions that steer answer in a certain way Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Structuring Used to create order, establish guidelines – This helps patients become aware of problems and the order in which to deal with them – Useful when patient introduces a lot of issues, doesn’t know where to begin Can be used to define parameters of nurse–patient relationship – How nurse will participate to facilitate problem solving Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Pinpointing Used to call attention to inconsistencies among statements, similarities and differences in points of view, feelings, actions Can be used to determine differences between a person’s actions, words Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Linking Nurse responds to patient in a way that ties together events, experiences, feelings, or people Can be used to connect past experiences with current behaviors Can be used when there is tension between individuals in times of stress Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Giving Feedback Nurse shares reaction to patient’s statements or behaviors Can help patient become aware of how his/her actions, behaviors affect others Nurse may engage in therapeutic self-disclosure to offer constructive information about how patient’s words or actions have affected the nurse – Total self-disclosure is inappropriate in nurse–patient relationship Qualities of effective feedback – Immediate – Honest – Supportive The more defensive patient is, the less able patient is to hear, understand feedback – Nurses should be very careful to prevent patient from feeling rejected Feedback goes both ways Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Confronting Deliberate invitation to examine some aspect of personal behavior – Typically a discrepancy between actions and words – Also used when actual behavior differs from expected behavior Can lead to productive change when used constructively Requires careful attention to nonverbal communication Informational confrontation – Describes visible behavior Interpretive confrontation – Expresses thoughts and feelings about behavior – Draws inferences about the meaning of behavior Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Summarizing Highlighting the main ideas expressed during interactions Conveys nurse’s understanding to patient Reviews main themes of conversation Can be useful to focus patient’s thinking, aid in conscious learning Particularly appropriate in certain instances – First few minutes of patient interaction to review previous interactions ▪ Helps patient recall what was discussed ▪ Gives patient opportunity to see how nurse synthesized information from previous encounters Keeps all participants directed toward common goal Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Processing Complex, sophisticated technique to direct attention to interpersonal dynamics of nurse–patient relationship – In terms of content, feelings, behaviors that have been expressed Advanced skill Most useful, meaningful when therapeutic intimacy has been achieved Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Common Mistakes Giving advice Minimizing or discounting patient’s feelings Deflecting Interrogating Sparring Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved The Therapeutic Relationship (1 of 2) Nurse promotes trust and helps patients – Manage their health challenges, use opportunities, resources more effectively – Become better at managing their own needs and resources – Develop tools to prevent health problems and recurrences To develop a therapeutic relationship – Patient requires time and attention ▪ To promote the patient’s trust in the nurse ▪ Acceptance of the nurse’s role in providing care Good communication skills and a sincere interest in patient’s – Help the nurse overcome factors – Can affect development of relationship, including gender, age, or cultural differences Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved  Phases of the Therapeutic Relationship Phase Notes Preinteraction phase Introductory phase Working Phase Termination Phase Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Developing Therapeutic Relationships Purpose of the therapeutic relationship is to establish mutual goals Many ways of helping do not require special training – Help identify the patient’s feelings – Be honest – Be genuine and credible – Use your ingenuity – Be aware of cultural differences that may affect meaning, understanding – Maintain confidentiality – Know your role and your limitations Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (1 of 6) Nurse must provide appropriate environment for nurse–child–family communication – Ensuring confidentiality Communicating with children and families – Techniques used to communicate with children and families include ▪ Accepting ▪ Active listening ▪ Broad openings ▪ Clarifying ▪ Collaborating ▪ Exploring ▪ Focusing ▪ Giving recognition ▪ Observation Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (2 of 6) Communicating with children and families – Techniques used to communicate with children and families include ▪ Offering self ▪ Placing event in time or sequence ▪ Restating or paraphrasing ▪ Summarizing ▪ Validating perceptions Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (3 of 6) Establishing rapport with children – Position self at child’s eye level – Show interest in what child is doing – If appropriate, agree with child and possibly share feelings – Compliment child – Use calm tone of voice, developmentally appropriate language – Pace discussion, procedure so that child does not feel rushed – Explain concepts in terms child can understand – Include child in discussion if developmentally appropriate – Listen more than you talk – Avoid distractions Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (4 of 6) Establishing trust with children and families – Follow through on promises made to child and family – Respect confidentiality – Be truthful, even if truth isn’t what child and family want to hear ▪ Follow with positive words or comforting statement if truth is painful Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (5 of 6) Communicating with pregnant women – Important because physical health of woman and fetus, emotional health of woman are at stake – Keys to communication ▪ Relate medical information clearly ▪ Listen for patient questions, concerns ▪ Use active listening ▪ Silence may allow patient to express herself fully ▪ Making observations allows patient to communicate without lengthy questioning Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (6 of 6) Communicating with older adults – Older patients may have conditions making communication difficult ▪ Visual impairments ▪ Hearing impairments ▪ Cognitive impairments – Nurse may need to adjust therapeutic communication strategy ▪ Sensory impairments require nurse to choose techniques tailored to patient’s needs ▪ Nurse can research assistive communication devices, involve patient’s family in communication process – Nurse must continuously reevaluate patient’s communication needs – Nurses should acquaint selves with patient’s family and friends ▪ Learn about relevant health concerns ▪ Patient’s favorite conversational topics Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Conclusion Effective communication is essential to the nurse’s ability to provide high-quality care Throughout each stage of care – Assessment – Planning – Implementation – Evaluation Important that nurses be understood and understand the messages they receive Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Normal Vital Signs Across the Lifespan Table 34-3 Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved  Exemplar 38.C Documentation Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Exemplar Learning Outcomes 38.C Analyze documentation as it relates to communication. Outline the legal and ethical considerations of documentation. Summarize the purposes of patient records. Outline various types of documentation systems. Summarize the documentation of nursing activities. Describe facility-specific documentation. Outline general guidelines for recording documentation. Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Overview Healthcare personnel normally communicate through a variety of methods – Discussion ▪ An informal oral consideration of a subject by two or more people – Reports ▪ Communication intended to convey information – Records ▪ Recording, charting, or documenting: process of making an entry on a patient record Each patient record is a formal, legal document Joint Commission, other accrediting agencies require patient record documentation Following requirements of their employing organization’s accrediting agency – Organization’s specific policies for documenting reporting patient information Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Ethical and Legal Considerations (1 of 2) American Nurses Association Code of Ethics – Nurse has duty to maintain confidentiality of all patient information – Nurse follows agency policies to maintain the privacy of the patient’s record – Access to patient's record restricted to healthcare professionals involved in giving care to that patient – Legally protected as official documentation of care provided to the patient – Patient medical records are legally owned by the healthcare agency HIPAA includes regulations about maintaining the privacy, confidentiality, and security of protected health information, or PHI – Identified health information that is recorded or maintained in any format ▪ Electronically ▪ Digitally ▪ On paper Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Ethical and Legal Considerations (2 of 2) Student healthcare professionals may access patient records – For education purposes, research – For use in patient studies, conferences – In clinical rotations or rounds Use of electronic records came need for – Policies, procedures to ensure the security, confidentiality of patient information stored electronically To protect electronic patient information, each member of the healthcare team should – Have a personal login and password for accessing patient records – Log off a computer when not actually using – Make sure information is not displayed for anyone else to see while in use – Know the agency’s policy for correcting an entry error – Follow agency policies for documenting sensitive material Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Problem-Oriented Medical Record (POMR) (1 of 4) Data arranged according to patient problems rather than source of information Advantages – Encourages collaboration – Allow for rapid identification of current patient needs ▪ Make it less difficult to track status of each problem Disadvantages – Caregivers vary in their ability to use the required charting format – Challenging and inefficient to maintain a current problem list – Assessments and interventions that apply to more than one problem must be repeated – Causing documentation to be extremely time-consuming Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Problem-Oriented Medical Record (POMR) (2 of 4) Components of POMR – Database ▪ Contains all the data gathered on admission – Results of initial assessments – Baseline diagnostic tests ▪ Information is updated in the database – Problem list ▪ Problems listed in order in which they are identified ▪ All members of the healthcare team may contribute to a patient’s identified ▪ Primary HCPs entering medical diagnoses and order ▪ Problems may be redefined as the patient’s condition changes Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Problem-Oriented Medical Record (POMR) (3 of 4) Components of POMR – Plan of care ▪ Member of healthcare team who identifies problem ▪ Generates care plan for addressing that problem ▪ Written plan of care is listed in progress notes associated with problem, not isolated in a separate list of orders or interventions – Progress notes ▪ May be made by any member of healthcare team – Providing care to the patient ▪ Progress notes correlate to identified problem on problem list ▪ SOAP or SOAPIER format used Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Problem-Oriented Medical Record (POMR) (4 of 4) SOAPIER format – Subjective data – Objective data – Assessment – Planning – Interventions – Evaluation – Revision Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved PIE Model Groups information into three categories – Problems – Interventions – Evaluation of nursing care System, based on nursing process, consists only of patient care assessment flow sheet and progress notes – Flow sheet follows a specific format, such as basic human needs – After assessment is completed, nurse establishes, records identified problems on progress notes Problem statement, which is labeled “P” and identified by a number Interventions planned to address problem are labeled “I”, numbered to match problem Evaluation of patient’s response to interventions is labeled “E”, numbered to match problem Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Focus Charting Systematic approach to documentation that is intended to make the patient’s strengths and needs focus of care Three columns for recording – Date and time, focus, and progress notes ▪ Data – Information gathered during assessment ▪ Action – Planning and implementation phase and includes immediate and future nursing interventions ▪ Response – Evaluation phase of nursing process Provides holistic perspective of patient, patient’s needs Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Charting by Exception (CBE) Significant or unexpected findings or exceptions to defined norms are recorded Three key elements – Flow sheets – Standards of nursing care – Bedside access to records Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Electronic Documentation (1 of 3) Computerized clinical record systems are fastest-growing sector in documentation Electronic health record (EHR) or electronic medical record (EMR) systems – Efficient way to manage huge volume of information required in contemporary healthcare Nurses use computer databases to store patient data, add new data, create and revise care plans, and document patient progress Computer terminal at each patient’s bedside or a laptop or tablet for nurse to carry EHRs and EMRs use standardized lists, drop-down menus, narrative information entered by nurse to document, record patient assessment and care information Paraprofessional trained to enter physician assessment data and medical orders directly into EMR Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Electronic Documentation (2 of 3) Electronic health records have made it possible to transmit information Nursing minimum Data Set (MDS) is a classification system Electronic medical records contain standard medical and clinical data gathered in one provider’s office EHR data can be created, managed, and consulted by healthcare staff within the same agency – As well as across any number of healthcare organizations Electronic medication administration records (eMARs) – Are specifically used to keep track of patient medication information EMRs and EHRs are more useful than paper records by most measures Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Electronic Documentation (3 of 3) Electronic medication administration records (eMARs) – Used to keep track of patient medication information – Barcodes, handheld scanner used to send and fill prescriptions – Includes ▪ Medication dosages ▪ Number of refills ▪ Types of medications ▪ Medication classifications ▪ Refill history ▪ Prescription status ▪ Tracking information – Accelerate prescribing process – Quality assurance, audit-tracking features help to limit possibility of medication error Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Case Management and the Critical Pathway Emphasizes high-quality, cost-effective care delivered within established period Uses interprofessional approach to planning and documenting patient care Critical pathways identify – Outcomes that certain groups of patients expected to achieve on each day of care – Interventions necessary for each day Incorporate the use of graphics, flow sheets, and critical pathways Enter progress or narrative notes to chart by exception Variance: unexpected response that affects that plan of care – Documentation ▪ Unexpected event the cause ▪ Interventions used in response to the variance Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Documenting Nursing Activities Document evidence of nursing – Assessments – Interventions – Interaction Patients regardless of type of records system used in an agency Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Admission Nursing Assessment Comprehensive admission assessment is completed, patient is admitted to nursing unit Also be referred to as an initial assessment, health history, or nursing assessment Purpose of the assessment – Evaluate the patient’s health status – Identify functional health problems – Establish a comprehensive database May be organized according – Type of healthcare setting – Body systems – Functional health patterns or abilities – Nursing or medical diagnoses Entered as part of the critical pathway or through nursing progress notes Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Nursing Care Plans Joint Commission and other accrediting agencies require that each patient’s medical record include – Documentation of assessments – Nursing diagnoses or patient care priorities – Nursing interventions – Patient outcomes – Evidence of a current nursing plan of care Clinical Decision making, for information on types of nursing care plans – Approaches to their development and use Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Flow Sheets Enable nurse to record data quickly, concisely Provide easy-to-read record of patient’s condition over time Include – Graphic record – Input and output (I&O) record – Medication administration record – Skin assessment record Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Progress Notes Nurses enter progress notes to document – Patient’s progression toward expected or desired outcomes – Any problems or exceptions – Nursing interventions – Evaluations of patient responses to interventions Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Nursing Discharge/Referral Summaries Completion on discharge/transfer Many institutions provide forms Some records combine discharge plan and final progress notes May include checklists to facilitate data recording If given to patient, family, instructions must be written in understandable terms If patient being transferred within the facility or to/from a long -term care facility – Report goes with patient for continuity of care – Includes all components of discharge instructions – Also describes patient’s condition before transfer – Any teaching or patient instruction done should be described, recorded If patient being transferred to setting or home where home health nurse required – Discharge note takes form of referral summary Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Facility-Specific Documentation Documentation systems and requirements vary by facility – Acute care setting – Long-term care setting – Home care – Other care delivery sites, such as outpatient clinics Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Long-Term Care Documentation (1 of 2) Long-term facilities provide intermediate care – Patients who need rehabilitation Long-term care facilities provide two types of care – Assistance with ADLs following discharge from the hospital Provide comprehensive, specialized nursing care – Progressed to the point they can no longer be cared for safely at home Number of laws provided standards for documentation systems – Omnibus Budget Reconciliation Act of 1987 requires Long-term care facilities conduct assessment within 4 days after admission Formulate a plan of care within 7 days after admission Long-term care facilities must also fulfill requirements set by Medicare and Medicaid Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Long-Term Care Documentation (2 of 2) Nursing care summary – Completed ▪ Every week (for patients requiring skilled care) ▪ Every 2 weeks (for patients requiring intermediate care) – Nursing care summaries document patient ▪ Mental status ▪ ADLs ▪ Safety measures needed ▪ Medications administered ▪ Other treatment ▪ Nutrition and fluid status ▪ Any assistive devices patient requires Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Home Care Documentation Home health services follow documentation requirements for Medicare, Medicaid, and other third-party reimbursement plans Home health nurse assigned to the patient is responsible – Completing a home health certification – Plan of treatment Home health nurse documents in patient’s medical record each interaction with patient Home care medical record – Includes reports to third-party payers – List of medications – Interprofessional plan of care – Referral and intake forms – Patient assessments Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved General Guidelines for Recording (1 of 4) Addition to maintaining confidentiality of records Nurses are charged with meeting legal standards of documenting information Recordings should include – Date and time – Timing ▪ Should document assessment finding as soon as possible after it occurs ▪ Documentation should not be recorded before event – Accepted terminology ▪ Should contain only approved abbreviations, symbols, terms ▪ Healthcare facilities are moving away from use of any abbreviations ▪ Require all organizations requesting accreditation to develop “Do Not Use” list of abbreviations, acronyms, symbols – Including those banned by Joint Commission Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved General Guidelines for Recording (2 of 4) Recordings should include – Correct spelling – Signature ▪ Nurses must sign in any nursing notes using name and title – Accuracy ▪ Document objective observations or facts, not personal opinions – Sequence ▪ Order in which events occur – Appropriateness ▪ Only information that is relevant to patient’s health status and care ▪ Inappropriate to document personal information patient shares with nurse Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved General Guidelines for Recording (3 of 4) Completeness – Reflect nursing process – Including all assessments and findings – Dependent and independent nursing interventions – Patient comments and responses to interventions – Patient progress and variances toward goals – Nurse communications with other members ▪ Patient’s condition or refusal must also be documented Conciseness – Brevity is important – Patient’s name and word patient can be omitted Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved General Guidelines for Recording (4 of 4) Legal prudence – Clinical record provides proof of assessments and interventions, overall quality of care provided to a patient – Admissible in court as a legal document – Adhering to standards – Nurses ensure best possible care is provided to patient Provider–Patient Communications – Use of electronic records has expanded to patient portals, secure email services – Any email messages to or from a patient become part of that patient’s record – Nurses should follow their organization’s policies for communication Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Do’s and Don’ts of Documentation (1 of 2) Do – Document a change in a patient’s condition and show that follow-up actions were taken – Read prior notes – Be timely – Use objective, specific, factual descriptions – Correct charting errors per agency policy – Document all teaching – Record patient’s actual words, using quotation marks – Document patient’s responses to interventions – Review notes to ensure clarity, accuracy Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Do’s and Don’ts of Documentation (2 of 2) Don’t – Document in advance of the event – Use vague terms – Document for someone else – Use “patient” instead of patient’s name – Alter a record ▪ Even if requested by superior or physician – Record assumptions or words reflecting bias Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Nursing: A Concept-Based Approach to Learning Volume Two, Fourth Edition Module 25 Development Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved  The Concept of Development Development Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Concept Learning Outcomes (1 of 2) 25.1 Describe the course of normal development. 25.2 Analyze theories of growth and development 25.3 Summarize the developmental milestones of individuals across the lifespan. 25.4 Differentiate alterations in development. 25.5 Outline the relationship between development and other concepts. 25.6 Explain the promotion of healthy development. 25.7 Differentiate common assessment procedures and tests used to examine development. 25.8 Analyze independent interventions nurses can implement for patients with alterations in development. Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Concept Learning Outcomes (2 of 2) 25.9 Summarize collaborative therapies used by interprofessional teams for patients with alterations in development. 25.10 Differentiate considerations related to the assessment and care of patients with alterations in development throughout the lifespan. Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved The Concept of Development Growth: physical change, increase in size – Indicators include height, weight – Growth rates vary during different stages Development: change in function, complexity, and skill level that progresses gradually throughout the lifespan – The behavioral aspect of growth – Moves from simple to complex skills Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Normal Development Principles of growth and development – Growth and development proceed in an organized manner affected by genetics and environment – Maturation affects growth and development – Proceeds in a predictable manner ▪ Time of onset, duration, and impact vary – Each developmental stage has own characteristics – Growth and development occur in cephalocaudal and proximodistal directions – Development proceeds from simple to complex or from single acts to integrated acts – Development becomes increasingly differentiated – Pace is uneven – Rate is highly individual Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Theories of Growth and Development Theories can be useful but have limitations – May explain only one aspect of growth and development ▪ Application of several theories might be necessary – May indicate that certain tasks are performed at certain ages ▪ Individual differences not easily categorized by a single theory Five major domains of growth and development – Psychosocial – Cognitive – Moral – Spiritual – Biophysical Other domains: behavioral, social learning, temperament, resiliency, ecologic Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Theories of Growth and Development Psychosocial theories – Psychosocial development: development of personality – Personality: consists of beliefs, attitudes, social interactions ▪ Distinct visible display of thoughts, feelings, and behaviors ▪ Endures over time, may be influenced by environment, life events, education – Freud ▪ Proposed many of the earliest theories about personality development ▪ Most relevant part of his work centers on development of ego defense mechanisms Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Theories of Growth and Development Psychosocial theories – Erikson ▪ Life is sequence of developmental stages or levels of achievement ▪ People continue to develop throughout life ▪ Each stage signals a developmental task that must be accomplished ▪ Health of personality depends on level of success at each stage or crisis –Resolution can be complete, partial, or unsuccessful –Unsuccessful resolution of conflict causes feelings of inadequacy ▪ Developmental stage and task to accomplish should be considered when planning care ▪ Development affected by environment Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Theories of Growth and Development Psychosocial theories – Erikson’s eight stages of development ▪ Infancy: birth–18 months ▪ Early childhood: 18 months–3 years ▪ Late childhood: 3–5 years ▪ School age: 6–12 years ▪ Adolescence: 12–20 years ▪ Young adulthood: 18–25 years ▪ Adulthood: 25–65 years ▪ Maturity: 65 years–death Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Growth and Development Through the Lifespan Individuals change and evolve constantly throughout life Some changes are subtle, highly individualized Other changes are apparent and represent developmental milestones common to all human beings at or near specific phase of growth and development Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Infants (Birth to 1 Year) (1 of 4) Physical growth and motor development – Birth weight doubles by 5 months, triples by end of first year – Height increases ~1 foot during first year – Physical growth closely associated with type, quality of feeding – Body organs function differently by age 1 than at birth – Changing body proportions mirror changes in internal organs – Increased control over body movements – Sensory function increases Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Infants (Birth to 1 Year) (2 of 4) Cognitive development – Brain continues to increase in complexity – Most growth involves maturation of cells – Only small increase in cell number – Object permanence is evolving – Behaviors provide clues to thought processes – Maturing brain interprets stimulation provided by sight, sound, feeling Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Infants (Birth to 1 Year) (3 of 4) Psychosocial development – Play ▪ Begins in reflexive manner as infants move extremities or grasp objects ▪ Manipulation of toys in next phase ▪ Interacting with others becomes part of play ▪ Solitary play with toys but enjoys presence of others ▪ Physical development enables infant to move toward, reach objects ▪ Cognitive ability reflected in purposeful manipulation of objects ▪ Toward end of first year, ability to move in space enlarges sphere of play Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Infants (Birth to 1 Year) (4 of 4) Psychosocial development – Personality and temperament ▪ Differences in responses to environment believed to be inborn ▪ Infant’s temperament cannot be changed –Parents can modify environment to promote adaptation – Communication ▪ Communication skills apparent a few weeks after birth –Express comfort by soft sounds, cuddling, eye contact –Express discomfort by thrashing extremities, arching back, crying ▪ Speaks several words by age 1 ▪ Infants, toddlers understand (receptive speech) more words than they can speak (expressive speech) Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Toddlers (1 to 3 Years) (1 of 3) Physical growth and motor development – Slower rate of growth – Requires limited food intake – Gross motor activity develops rapidly – Toddler develops control of elimination patterns Cognitive development – Moves from sensorimotor to preoperational stage of development – Early language use → ability to think about absent people, objects – Well-developed object permanence – Rudimentary problem solving – Creative thought – Understanding of cause-and-effect relationships Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Toddlers (1 to 3 Years) (2 of 3) Psychosocial development – More comfortable asserting autonomy, separating from primary care providers – Play ▪ Motor skills advanced ▪ Parallel play ▪ Imitative behavior ▪ Physical skills manifested in play – Personality and temperament ▪ Retains most temperamental characteristics from infancy ▪ May show some changes related to developmental progression ▪ Increasing independence ▪ Parent and child adapt responses to each other, relearn how to communicate Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Toddlers (1 to 3 Years) (3 of 3) Psychosocial development – Communication ▪ Capacity for language skill development greatest in this period –Adults should communicate frequently with children this age Critical for cognitive and language development ▪ Begin to learn social interactions, nonverbal gestures ▪ Vocabulary of almost 1000 words ▪ Communication includes pointing, pulling adult to object, expressive jargon, crying, pounding or stamping feet, temper tantrum ▪ Adults can assist toddler by verbalizing toddler’s feelings ▪ Parents, nurses promote communication –Speaking frequently, naming objects, giving single-step directions ▪ Optimal age to learn two languages Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Preschool Children (3 to 6 Years) (1 of 5) Physical growth and motor development – Growth steady, slow – Most growth in long bones of arms, legs – Physical skills continue to develop – Writing ability increases Cognitive development – Preoperational thought – Symbols or words used to represent objects, people Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Preschool Children (3 to 6 Years) (2 of 5) Psychosocial development – More independent in establishing relationships – Interacts closely with children, adults – Can plan, carry out activities – Play ▪ Interactive, associative ▪ Large motor activities ▪ Increased manual dexterity ▪ Powerful fantasy life → dramatic play ▪ American Academy of Pediatrics (AAP) recommends limiting screen time to 1 hour/day, only for educational programming or video chatting Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Preschool Children (3 to 6 Years) (3 of 5) Psychosocial development – Personality and temperament ▪ Characteristics of personality observed in infancy tend to persist ▪ May need assistance as characteristics expressed in new situations ▪ Encourage parents to identify child’s temperament, find best environment for growth Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Preschool Children (3 to 6 Years) (4 of 5) Psychosocial development – Communication ▪ Vocabulary increases to >2000 words –Grasp of meaning usually literal, may not match that of adults ▪ Complete sentences of several words, all parts of speech ▪ Sophisticated speech –Mirrors development in children’s mind –Helps children learn about the world around them ▪ Concrete visual aids enhance teaching ▪ Allow time for child to integrate explanations ▪ Verbalize frequently to child ▪ Use drawings and stories to explain care ▪ Use accurate names for bodily functions ▪ Allow choices Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Preschool Children (3 to 6 Years) (5 of 5) Psychosocial development – Communication continued ▪ Perfect time to introduce concepts related to problem solving ▪ Children can learn to calm selves when upset ▪ Using language to resolve conflict is protective factor Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved School-Age Children (6 to 12 Years) (1 of 5) Physical growth and motor development – Boys, girls still close in size, proportions – Long bone growth continues – Fat gives way to muscle, child appears leaner – Body organs and immune system mature ▪ Fewer illnesses – Medications less likely to cause serious side effects – Physical skills refined – Fine motor skills well developed – Nutritional needs increase dramatically with growth spurt – Loss of first deciduous teeth, eruption of permanent teeth Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved School-Age Children (6 to 12 Years) (2 of 5) Cognitive development – Concrete operational thought at about age 7 ▪ Consider alternative solutions, solve problems ▪ Continue to rely on concrete experiences and materials to form thought content – Learns concept of conservation – Understands that healing will occur – Learns to read – Can concentrate for longer periods Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved School-Age Children (6 to 12 Years) (3 of 5) Psychosocial development – Play ▪ Enhanced by increasing fine and gross motor skills ▪ Understands team roles ▪ Eager to learn rules, want to ensure that rules followed exactly ▪ Cooperative play ▪ Increasing desire to spend time with friends ▪ Play is extremely important method of learning, living Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved School-Age Children (6 to 12 Years) (4 of 5) Psychosocial development – Personality and temperament ▪ Enduring aspects of temperament continue ▪ Child classified as "difficult" may have difficulty in classroom ▪ “Slow-to-warm-up” child may need encouragement to try new activities ▪ “Easy” child will readily adapt to new schools, people, experiences – Communication ▪ Learn how to correct lingering pronunciation and grammatical errors ▪ Learn pragmatic (social) use of language ▪ Vocabulary increases, parts of speech learned in school ▪ More technologically savvy with communication ▪ Enjoy writing ▪ Not limited to literal meanings of words Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved School-Age Children (6 to 12 Years) (5 of 5) Psychosocial development – Sexuality ▪ Awareness of gender differences, sexuality ▪ Need information about bodily changes ▪ Interested in sexual issues ▪ Friends, media common sources of misinformation ▪ Appropriate, inappropriate touch ▪ Encourage child to go to more than one person if uncomfortable about relationship with any individual Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adolescents (12 to 18 Years) (1 of 5) Physical growth and motor development – Puberty – Growth spurt in prepubescent period ▪ In girls: accompanied by increase in breast size, growth of pubic hair ▪ In boys: accompanied by growth in size of penis and testes, growth of pubic hair –Deeping of voice and facial hair occurs later, at puberty ▪ Some lack of coordination in both boys and girls – Stronger, more muscular – Male, female patterns of fat distribution – Apocrine, eccrine glands mature → sweating, distinct odor to perspiration – Body organs fully mature – Adult doses of medications Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adolescents (12 to 18 Years) (2 of 5) Cognitive development – Formal operational thought – Develops ability to reason abstractly ▪ Spends much time thinking, reading, talking about abstract concepts – Seek to establish own identity, values ▪ May rebel against parental authority ▪ Try to balance need to express themselves with expectations of parents, teachers, other authority figures Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adolescents (12 to 18 Years) (3 of 5) Psychosocial development – Activities ▪ Central focus for adolescents ▪ Drive independently ▪ More time with friends, doing activities ▪ Participation in sports, extracurricular activities ▪ Activities drive psychosocial development –Peer group becomes focus of activities ▪ Same-sex interactions predominate ▪ Social media, texting, other interactive technology part of social life – Personality, temperament ▪ Characteristics remain stable ▪ Adolescent who was “easy” child may become more difficult because of psychologic changes of adolescence, need to assert independence Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adolescents (12 to 18 Years) (4 of 5) Psychosocial development – Communication ▪ All parts of speech used, understood ▪ Often use colloquialisms, slang ▪ Increasingly leaves home base, establishes close ties with peers ▪ Period of stress or crisis occurs before strong identity can emerge ▪ May try out new roles ▪ For self-identity, need to leave past, be different, change from former patterns, may break rules ▪ Privacy Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adolescents (12 to 18 Years) (5 of 5) Psychosocial development – Sexuality ▪ Physical maturation, increased hormonal secretion ▪ Growing interactions with members of opposite sex ▪ LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) adolescents more subject to bullying, violence, harassment – May lead to substance abuse, mental health problems, suicide ▪ Benefit from – Clear information about sexuality – Opportunity to develop relationships with adolescents in various settings – Atmosphere at home and school where problems, issues can be discussed – Previous experience in problem solving, decision making Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adults (1 of 3) Transition from adolescence to adulthood complex No clear milestones Young adult: starting at 18 years – Still growing ▪ Men might not reach full height until around age 20 ▪ Human brain not fully mature until around age 25 – Peak of physical development in early to mid 20s – Mortality and morbidity caused mainly by unintentional injury, intentional trauma – Health assessment should include vision and hearing screening ▪ “Earbud” generation – Assessment questions should address stressors, diet, activity level and exercise, family history, smoking history, alcohol/substance use, sexual history Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adults (2 of 3) Middle adult: 40–65 years – Body begins to experience age-related changes – Risk factors for heart disease, related vascular problems – Arthritis and back problems may arise – Difficulty in mobility may cause disability – Health assessment should include vision and hearing screenings, vital signs, height, weight, body mass index (BMI) – Assessment questions should address activity levels and exercise, diet, family history, alcohol/substance use, smoking history, stressors, sexual history – Health screenings may include Pap smears, mammography, colonoscopy, fasting glucose, lipid panels Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Adults (3 of 3) Older adult – Begins at age 65 in United States – Loss of friends, relatives, spouses – May lose physical capabilities – Many live healthy, active lives that may include sexual activity – Advancements in preventive medicine and healthcare → transitioning to older adulthood with few chronic conditions – Chronic conditions can be complicated by normal changes of aging – Increase risk for cardiovascular disease, cancer, type 2 diabetes, neurocognitive disorders – Health assessment ▪ Height and weight especially important ▪ Safety assessment ▪ Mental status assessment Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Alterations to Development Developmental disabilities: a cluster of conditions occurring as result of impairment in – Motor function – Speech and language development – Behavioral patterns – Learning ability Alterations can occur at any point in lifespan Nurses must – Be knowledgeable about normal developmental milestones – Assess each patient’s individual developmental level – Incorporate the patient’s developmental level into plan of care ▪ Especially important in teaching and planning for patient care after discharge Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Alterations and Manifestations (1 of 2) Communication – Communication disorder: any delay or deficit in speech, language, voice, or swallowing – Children with developmental delays and cognitive differences benefit from learning sign language Motor function – Motor delays may be seen in fine motor skills, gross motor skills, or both ▪ More easily identified as child fails to achieve certain milestones or loses previous gains – Some children with developmental delays achieve milestones at later age – Some children never meet certain milestones Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Alterations and Manifestations (2 of 2) Cognition – Cognitive delay: difficulty with thinking and problem solving in relation to developmental milestones – Preterm infants at greater risk for cognitive delays – Cognitive delays seen in a variety of disorders ▪ Autism spectrum disorder ▪ Cerebral palsy ▪ Down syndrome Adaptive functioning – Encompasses life and social skills – Difficulty adapting to different people and environments → many challenges – Adaptive functioning and cognition closely linked – Poor executive function is associated with poor adaptive behavior in children with histories of heavy prenatal alcohol exposure Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Etiology Alterations in development may stem from many different etiologies – Example: visual impairments in neonates can be caused by ▪ Congenital anomalies, infantile glaucoma, or retinopathy of prematurity A single defect may manifest as array of signs, symptoms – Example: fragile X syndrome ▪ Impairments related to language, learning, social interaction Developmental disabilities may stem from exposure to fetal toxins ▪ Example: fetal alcohol spectrum disorders –Intellectual and neurologic, visual and hearing, behavioral and mental health problems Infectious agents such as viruses, bacteria – Example: Zika virus ▪ Impaired growth, microcephaly, neurologic deficits, vision and hearing issues Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Prevalence Approximately 1 in 6 children in the United States is impaired by one or more developmental disabilities Trends show an increase in developmental disabilities from 2009–2011 and 2015– 2017 in children age 3 to 17 ADHD, ASD, and intellectual disabilities continue to have rising rates – Theories to explain rising rates ▪ Greater awareness of autism ▪ Better diagnostic tools ▪ Change in language used in polling parents Other disabilities tracked by Centers for Disease Control and Prevention (CDC) – Intellectual disability – Cerebral palsy – Vision and hearing loss Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Genetic Considerations and Nonmodifiable Risk Factors Genetic abnormalities Chromosomal disorders Premature birth Multiple gestation Low birth weight Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Concepts Related to Development Assessment Family Health, Wellness, Illness, and Injury Safety Stress and Coping Trauma Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Nursing Assessment Developmental theories – Guide assessment – Explain behavior – Provide direction for nursing interventions – Help nurse to anticipate and explain some reactions, responses, needs – Help nurses to encourage patient behavior appropriate for a particular developmental stage Assessment of patients with developmental differences requires – Foundation in developmental theories and concepts – Understanding of the impact of differences Understanding of development can provide better understanding of patient’s perspective of pain, treat accordingly Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Observation and Patient/Family Interview Parents, caregivers are reliable resource of child’s behavior, milestones Conduct assessment in well-lit, quiet room with space for family, patient, nurse Plan for plenty of time, do not rush observation/interview process Observe child for behaviors, physical traits Interview should be family centered, culturally competent, specific to patient’s age, developmental stage Open-ended questions Provide interpreter as necessary Be aware of cultural considerations involving questions, child’s behavior Include complete health history Compare expected findings with assessment results Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Cultural Considerations Nutritional practices Childrearing practices – Take cultural practices into account in performing developmental screening – Some tests might inaccurately label child as delayed – Delay of milestone might go unrecognized because of culture Patterns of social interaction – Language acquisition ▪ Number of languages ▪ Amount of speech in home – Social roles of men and women – Attitudes toward touching, other methods of encouraging skills Genetic traits in certain ethnic or cultural groups may influence other physical characteristics Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Physical Examination Review of systems Height, weight, BMI – In young children, changes in weight/BMI might indicate nutritional or developmental issues Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Diagnostic Tests Laboratory diagnostic tests generally are not used to determine developmental status Medical examinations rule out organic reasons Most helpful in determining developmental status – Observational tools – Questionnaires – Screening tests Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (1 of 3) Adolescents and younger adults – Like peers, teens with developmental differences seek greater independence ▪ May have difficulty with this stage and need greater support, encouragement – Children “age out” of system at age 18 or high school graduation, lose many supports available at younger ages – Challenges in this stage of development ▪ Transitioning to work or college ▪ Augmenting strained financial resources ▪ Navigating disability program requirements, restrictions – Children with significant cognitive and/or adaptive impairments may leave home later in life or never leave home ▪ Parents may worry about how to plan for adult child’s safety after parents die – Risk for abuse, exploitation ▪ Group home or assisted living can provide safe environment Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (2 of 3) Pregnant women – More at risk for maternal and neonatal complications – More likely to experience preterm birth, stillbirth, and low birth weight – Poor prenatal care – Higher risk for gestational diabetes and preeclampsia – Require careful interprofessional care during and after pregnancy Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Lifespan Considerations (3 of 3) Older adults – Live independently or with a spouse – Increased risk for type 2 diabetes – Assessment needed to rule out an emerging neurocognitive disorder – Communication deficits leads to challenging behaviors ▪ Caregiver burnout –Especially with increased cost for care, often fragmented resources – Long wait for services Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved Copyright This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials. Copyright © 2023, 2019, 2015 Pearson Education, Inc. All Rights Reserved