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Communication, Education and Documentation
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Transcript
ASN 110: Fundamentals of Nursing I
ozarks technial community college
Communication, Education, and Documentation
Communication, collaboration, and report.
01
Patient Education in Nursing Practice.
02
Documentaiton in the Electronic Health Record.
03
Communication
Test Yourself
FILL IN THE BLANKS
nursing
therapeutic
clinical
health
reviews
outcomes
communication techniques contribue to achieving positive patient
Use of both professional and
outcomes
therapeutic
nonverbal
clinical
nursing
therapeutic
written
subconcious
communication
communication. It includes eveyrthing except spoken or
The five senses are used in
written
nonverbal
posture
relevance
expression
nonverbal
written
verbal
communication
and meaning are all aspects of
Vocab, pacing, tone, clarity, timing,
verbal
relevance
Patient Education
Test Yourself
Patient Education
You are a nurse in a hospital in the Neurological (disorders of nervous system) Unit. Prepare your patient to discharge.
start
Mrs. Johnna Smith
Your patient is a 52-year-old single woman who was recently hospitalized due to an embolic stroke. She has left-sided weakness and currently has no fine motor skills on her left side. During her hospitalization she was found to have untreated hypertension and high cholesterol. She was started on multiple new medications including an anticoagulant ("blood thinner") for secondary stroke prevention along with a medication for hypertension and a medication for high cholesterol.
next
Click the green button to see what outcomes your clinial judgement has led to.
What members of the interdisciplinary team should the nurse include when planning for this client's discharge?
The client will need further therapy due to weakness, a dietitian due to high cholesterol, and a consult with pharmacy due to multiple new medications.
The client will have home health that will manage all aspects of care following discharge.
The client needs no additional resources as they are preparing to discharge to home.
Click the green button to see what outcomes your clinical judgement has led to.
The patient has orders to begin a mobility program. When preparing to instruct the patient on the mobility program protocol, she reports she is feeling fatigued. Which of the following learning principles will likely be affected by this patient’s condition?
Motivation to learn.
Readiness to learn.
Developmental stage.
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Which of the following scenarios demenstrate that patient education was successful?
The patient describes how to set up a pill organizer for newly ordered medicines.
The patient listens to a nurse’s review of the warning signs of a stroke.
The patient reviews written infomration about resources for stroke survivors.
Click the green button to see what outcomes your clinical judgement has led to.
The nurse is preparing to teach the client how to identify the signs and symptoms of a stroke. Which action is appropriate for the nurse to perform first?
Set mutual goals for the educational session.
Use teach-back to ensure the goals of the seesion are met.
Assess the client's understanding of a stroke and previous health status.
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The nurse utilizes the clinical judgement model to develop this patient's educational plan. What is the first step of the clinical judgement model where the nurse will gather pertinent information?
Analyze Cues
Recognize Cues
Assessment
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The nurse generates a hypothesis of 'Lack of Knowledge' related to medication chagnes due to recent cerebrovascular accident. Which solution would be appropriate for this nursing hypothesis?
The patient will understand medications and take them at all times by time of discharge.
The patient will verbalize correct timings of medication and risks associated with medications by time of discharge.
The nurse will consult the pharmacist in order to provide medication education to this client by time of discharge.
Click the green button to see what outcomes your clinical judgement has led to.
The nurse is going to begin teaching this client about the different medications. What time would be best for this nurse to provide education?
At time of discharge to ensure teaching is appropriate.
When the patient is attentive, receptive, and alert.
At time of admission to ensure there is enough time for education.
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The following solution (goal, outcome) is set for the patient: "The patient will verbalize correct timings of medication and risks associated with medications by time of discharge,". Which Intervention would assist the patient in meeting this goal?
The patient will take their medications during each medication administration.
The nurse will copy pages from the drug information guide and give them to the patient.
The nurse will provide education on medication during each medication adminsitration.
Click the green button to see what outcomes your clinical judgement has led to.
How would the nurse evaluate if education was successful for the solution (goal/outcome): "The patient will verbalize correct timings of medication and risks associated with medications by time of discharge,"?
Have the patient utilize the teach-back method to provide timings of medication and different risks associated with the medications.
The nurse completing all interventions set and all scheduled educational sessions.
The patient discharging to home.
Click the green button to see what outcomes your clinical judgement has led to.
The nurse should assess what factor in order to determine if this patient has the skills needed to manage health and prevent disease?
Health Literacy
Education
Age
Great Job
You provided some great discharge education!
The patient went home with an understanding of new medications and when to seek emergency care. The nurse worked with the social worker to set-up necessary resources such as home health and meals on wheels to ensure the individual has healthy foods while recovering. Additionally, the patient has follow-up appointments scheduled.
Next
Restart
Good job
They're headed home
Not all answers provided were the best options. While the client was still provided the necessary education to discharge home, review rationale to understand what areas required further attention. Good job, overall, and keep up the hard work!
Next
Restart
keep trying
he isn't ready to go home yet
Discharge education begins at the time of admission. Unfortunately, this client hasn't received the necessary education to safely discharge home. Please try again.
Next
Restart
Documentaiton
Test Yourself
SECRET CLUES
Find the secret clues with the magnifying glass
start
A nurse contacts the health care provider about a change in a patient’s condition and receives several new orders for the patient over the phone. When documenting telephone orders in the EHR, what should the nurse do?
Record telephone orders in the EHR but wait to implement the order(s) until they are electronically signed by the health care provider who gave them.
“Read back” all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR.
Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes.
01 / 05
Drag the magnifying glass to discover the 3 options and then choose the correct answer
The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contains an inappropriate abbreviation included on TJC’s “do not use” list and should be clarified with the health care provider?
Change open midline abdominal incision daily using wet-to-moist normal saline and gauze.
Lorazepam 0.5 mg PO every 4 hours prn anxiety
Morphine sulfate 1 mg IVP every 2 hours prn severe pain
Insulin aspart 8u SQ every morning before breakfast
Insulin aspart 5 units SQ ACHS
02 / 05
Drag the magnifying glass to discover the 5 options and then choose the correct answer
The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation?
1015: Contacted the surgeon and notified about changes in abdominal incision. T. Wright, RN
Documentation not needed as order will be placed by provider
Health care provider notified about change in assessment of abdominal incision. T. Wright, RN
09-3-21 (1015): Surgeon contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN
Notified the surgeon by phone that there is a new area of redness around the patient’s incision. T. Wright, RN
Utilize flow sheets per unit standards to document phone call and assessment.
03 / 05
Drag the magnifying glass to discover the 7 options and then choose the correct answer
Which of the following is not considered to be an element of protected health information (PHI)?
Employment Records
Telephone number
Voiceprints
Birth date
Names
Medical Record Number
Internet Protocol (IP) address
Geographic information smaller than a state (i.e. street name, city).
04 / 05
Drag the magnifying glass to discover the 10 options and then choose the correct answer
This item helps nurses develop and document nursing plans of care based upon evidence-based practice guidelines for identified problems:
Nursing Informatics
Admission nursing history form
SOAP Note
Clinical information system (CIS)
Diagnosis-related groups (DRGs)
Flow Sheets
Patient Care Summary
Clinical Practice Guidelines (CPGs)
hospital-acquired conditions (HACs)
Charting by exception (CBE)
Electronic Health Record System (EHRS)
Incident Report
05 / 05
Drag the magnifying glass to discover the 12 options and then choose the correct answer
Congratulations, you have passed all the clues and completed this lesson!
DETECTIVE WINNER
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Embolic strokes...
are caused by a wandering clot (embolus) formed elsewhere that travels and becomes lodged in the arteries of the brain resulting in decrease tissue perfusion (ischemia)
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