(Nursing Care of the Patient)
(1) Palliative care:-
This care is provided by organized health services to the terminal patient and his family.
(2) Fire drills:-
Practicing emergency procedures in times of fire are called fire drills.
(3) Confronting:-
To face a difficult situation or person means to meet or deal with.
(4) Insight:-
One’s capacity to understand a person or something deeply and accurately is called insight.
(5) LAMA:-
Living Against Medical Advice (Leaving Without Medical Advice)
(6)ECG:-
Electrocardiogram
(7) Admission:-
Admission of the patient to the hospital
(8) Unit :-
The space in which a client stays in a hospital is called a unit.
(9) Discharge:-
Patient’s exit from hospital.
∆ Patient environment in hospital
Patient’s Nearby Space
Importance:–
An environment that relaxes the mind, body and soul also makes the patient recover very quickly.
∆Therapeutic environment:-
A physical, social, and psychological safe space that is specifically created for the patient’s speedy recovery, but also a therapeutic environment is considered a physical space that helps the individual work and overcome medical issues.
∆Hospital Physical and Environmental Plan
-Should be a place with less population.
-Both wall and floor should be shock absorbent, non-porous, attractive, and fire resistant, durable, and easy to clean, the floor should not be too slippery, otherwise the chances of accidents may increase.
There should be no cracks in the walls and floors of the hospital, if there are, the germs will start living there.
-The floor area of the hospital should be of exact size to accommodate proper and adequate patient beds and should not and should not overcrowd the space.
-The number of windows and doors should be sufficient as windows play an important role in making the patient feel good.
-Toilets are kept away from the general ward and should be cleaned twice a day to avoid bad odor and clean toilets keep away many diseases and toilets should be built in a place where direct sunlight can fall on them.
-If there is a kitchen and dining area in the hospital, they are kept away from everyone, which helps in keeping the food safe and free from infection.
Isolation wards should be set up in hospitals so that if a patient has a communicable disease, they can be treated in a separate area to reduce the chance of passing the disease on to others and to health care providers.
-If any kind of emergency situation occurs inside the hospital like fire then it is mandatory to have at least one emergency exit inside the hospital.
S=Sense the error
A=Act to prevent
F=Follow Safety Guidelines
E = Inquiry
T=Take inappropriate remedial measures
Y=Your Responsibility
∆Safety measures within the hospital
-Never lower the railing of the hospital bed and ask the nurse to use the bed controls to avoid mistakes and not to use the bed side table for support over the bed.
Assessing the patient’s basic needs including emotional and mental well-being is called psychosocial needs.
-If we understand, we know that mental health is related to physical health, it means that if there is any effect on mental health, then it can also affect the body of the person physically. can
-Patients should have a sense of safety and security in all. Each person has a primary desire to be recognized as a unique person so that the patient feels rested in the relationship with the staff and with other patients and families.
Patient’s adjustment to hospital
A health care facility is an institution where health-related care is provided with patient-centered care.
As soon as the patient gets admission in the hospital, he has to face with the hospital staff, doctor, nurse, the environment of the hospital is different from the environment of the house, his daily routine changes and because of the change of the environment, he also feels anxiety, all this affects the emotional mental of the patient. And can change physically and for the patient, his income and socioeconomic status and culture can affect his health status.
Factors affecting patient’s adjustment to hospital:-
-Edge
-Gender
∆Patient’s reaction to hospitalization:-
Fear
Loneliness
Anxiety
Loss of Identity
∆Patient’s emotional reaction to hospitalization:-
Depression fills the patient.
The patient has irritability.
The patient also feels angry.
The patient perceives himself as dependent on others
Patient feels denial ∆Nurse’s role in adjusting the patient :-
Welcoming the patient.
The nurse should show empathy to the patient.
Always respect the patient.
No special treatment of any patient.
Always address the patient with the titles of Mr. and Mrs.
Do not try to impress the patient.
Listening to the patient.
Talk to the patient and ask him questions.
Helping the patient and his family to adjust.
Orient the patient and his family to vote.
Respecting patient privacy.
Explaining any procedure to the patient.
∆Cause of fear and anxiety.
The patient himself becomes isolated from his entire family.
There is fear of seeing the disease progressing itself.
The patient travels in pain.
The patient is afraid for his family that he will not get sick.
The patient feels fear and anxiety due to his economic problems.
∆Advantages of Hospitalization:-
DCs can be printed due to hospitalization.
Hospitalization promotes health.
Hospitalization helps cure the disease.
Admission
Definition:-
Admitting the patient to a hospital stay for observation, investigation and treatment of the disease from which the patient travels.
Emergency Admission:-
Emergency admission is done when the patient needs immediate treatment in an emergency situation for example heart attack, accident, labor pain, shock, hyperpyrexia in which the patient’s life is at risk.
Routine Admission:–
Routine admission is done when a patient has to be admitted to the hospital for investigation and planning for treatment and surgery.
∆Purpose of admission
To provide immediate care to the patient.
For the patient to get comput and safety.
For hospital staff to be ready for any emergency.
To take data from the patient.
: ∆Procedure of Admission
First of all, prepare the room, arrange all the items in one place and adjust the height of the bed.
Introducing oneself to the patient, checking the patient’s identification and greeting the patient and his relative.
To check patient’s vital signs and symptoms and if any specimen to be collected for lab.
To provide privacy to the patient and to provide an admission bath if the patient requires it.
Informing the patient about the ward and the visiting hours.
Answer any doubt to the patient and the patient’s relative.
To maintain reports and records.
: ∆unit and its preparation.
The place where the patient is kept during the hospital admission of the patient is called unit.
∆ Certain activities before the patient is admitted
Keep the patient ready Arrange the open bed.
The patient should be able to assess his bed easily and if necessary, increase or decrease the height of the patient’s bed.
Assembling of special equipment if required like oxygen cylinder, cardiac monitor, vacuum machine.
∆ PRINCIPLES OF ADMISSION:-
Illness can be a romantic experience for the patient that can also be stressful both physically and mentally.
People have different types of habits and behavior.
Entering a hospital is a threat to one’s personal identity.
A sadan change in the environment can produce fear and anxiety.
: Discharge
The nurse is responsible for the discharge of the patient. The planning and decision of the discharge is not at the point but from the starting when the patient enters the hospital, whether the condition has improved or not. After discharge, the patient has to be sent home or referred. . Within the discharge there will be all the advice which will help the patient for full recovery.
Cure and Discharge: When the patient’s treatment is complete and the patient is discharged as per the doctor’s order.
LAMA:- When the client wants to stop taking the treatment of his own accord and against the doctor’s medical advice, the client asks for discharge, it is called LAMA.
Abscond:- When the patient leaves all the treatment incomplete and escapes without any notification to the hospital staff it is called abscond.
Transfer to another hospital When a patient is referred to another hospital to receive better or specialist services.
∆Steps of Discharge:-
Take special care that the patient has return consent for discharge and follow up.
Inform the patient about all types of diet, medication and activity, exercise.
Signing in LAMA.
Asking to pack all the luggage so that nothing is forgotten.
Providing a discharge sleep with follow up care.
To complete records and reports.
Post-discharge care of the unit.
: ∆ Unit care after discharge
Cleaning the room before admission of another patient.
Prepare to send any used articles to the UTDT room and reuse them.
Discard anything
Consign used linen to laundry.
Fumigate the room if a patient has a communicable disease.
: ∆ Transfer Procedure
(1) Transfer from one Department to another Department
The doctor who is in charge will write the order.
The whole procedure has to be done like discharge, with records and reports to be taken to the department where the nurse or doctor is transferred to check everything and admission.
The patient has to be carried in a wheel chair or stretcher
To explain the entire procedure to the relative of the patient
(2) Transfer from one hospital to another
Inform the patient’s relatives of the purpose of transfer.
This procedure also has to be done like the procedure of discharge.
All the information about the patient’s condition should be available to the doctor of the hospital to which the patient is transferred.
[10:20 am, 6/4/2024] Aanad Bhai: Chapter 4 Communication
Communication has many meanings, depending on where the word is to be used. Communication is the exchange of ideas between two or more people.
Communication is a Latin word
“Communicare” means “to share”.
: Definition
Communication is a process in which a common system of symbols, signs, and behaviors is exchanged.
∆Purpose of Communication:-
To get information
To influence others
∆Purpose of Communication in Nursing:-
To collect assessment data
To begin the interview
To see the result of the intervention
To initiate changes that promote health
To analyze the factors affecting the health team
: ∆Elements of Communication:-
Source- Also known as the center, the person who sends the message or initiates the conversation is considered the source. Encoding means transmitting a message using a sign or symbol. For example word, language, how to arrange word, jester.
Message-message means conveying information to a person by expressing feelings verbally or non-verbally.
Channel- The medium used to convey a message is called a channel. Channel means targeting the senses of sight, hearing, touch, smell and taste to whom the message is to be delivered. Talking face to face is more effective than talking on the telephone or texting. A tape or television recording for a larger audience will be more effective. If the client hearing p…
∆Characteristic of Effective Feedback:-
Giving direct to point answers
Show honesty
Clear answer
Responding on time
: ∆ Level of Communication:-
(1) Interpersonal level –
This level of communication takes place between two people. This can be face to face or through telephone or any other media.The advantage of this level of communication is that it builds interpersonal relationships.
(2) Group Communication Level:-
In this level of communication three or more persons communicate simultaneously. This communication can be face-to-face or through any media. And this level is complex because the number of people increases. The leader of the group will always be at the front, people who are not interested sit too far back and people should be seated in a circle rather than in a line to make the group conference and interesting and increase interaction.
: ∆ Mode of Communication:-
Verbal Message – This is the use of words within the message and the language spoken or written. Within this message, the tone, pitch, speed, and volume of the voice are also included. Verbal messages can increase influence. If a man is speaking an unknown language and he is angry, the other person can understand the message by his actions like yelling, grunting, shouting, gnashing of teeth.
Non-verbal message- This message carries more weight than spoken language. Body language is more important than words in this message. The nurse has to pay more attention to the patient’s non-verbal message which includes his facial expression, posture, gesture, and touch and physical appearance. is
i: ∆Types of Communication.
There are many types of communication, including social, therapeutic, and formal, informal, and inclusive.
Therapeutic Communication- This communication is used to create a benefit out come for the patient. This communication establishes the nurse patient relationship and fulfills the purpose of nursing.
i: ∆ Characteristic of Therapeutic Communication:-
Gold Director and Propose Full
Depicting the boundary
Focused on the patient
Non judgmental
Well plane
: ∆ Elements of Therapeutic Communication
Empathy
Trust
Honesty
Valid
Caring
Active listening
∆Technique of Therapeutic Communication :-
The nurse should use communication techniques that allow the patient to have wide openings and some quietness so that he can be motivated to speak.
The nurse should make an open-ended comment so that the patient can respond to it later.
The nurse should also respond to the patient’s verbal and non-verbal cues and focus adequately on the patient.
The technique should be such that the patient can share his feelings.
: ∆ Barrier of Communication :-
Barrier of communication is a challenge for the nurse. If we understand the meaning of barrier, then the obstacle in communication is considered as a barrier
.
-Type of Barrier:-
(1) Language Barrier
unknown language
Lack of clear speech
Using jargon (a word whose meaning is known only to the speaker).
Not being spewific
Understand the Word
The picture does not explain
Having poor vocabulary
(2) Emotional or Psychological Barrier:–
Belonging to the trust
Lack of attention of the receiver
Failure to communicate
(3) Physical Barrier:-
Time being improper
Incorrect structure
Too much voice
Information overload
Nursing Interview
Introduction –
The word interview is a Latin word that means ‘seeing each other’. A general interview is just a formal meeting between the interviewer and the interviewee.
∆Interviewing technique while conducting health assessment
Active Listening:- Active listening encourages the patient to talk about his symptoms and the nurse should understand and respond to both verbal and non-verbal cues of the patient during the health assessment. The nurse should have complete focus on the patient.
Adaptive Questions:- Asking in such a way that the patient’s flow of speech is not interrupted so that the patient speaks and moves the question from general to specific that leads to an accurate response to the information. Within the health assessment, yes and no…
: Unit 2 Chapter 6
Nursing Record and Report :-
Introduction
Nursing is a profession in which a nurse has to record their work which is mandatory. A record is a practical and indispensable thing. It is a proof that all the persons of doctor, nurse and para medical are providing the service to the patient in the best way. The report summarizes the services provided to the person.
Definition of record:-
The clinical, scientific, administrative and legal document of nursing care provided to an individual, family or community is called a record.
Definition of Report:-
A report is a summary of service by a person or personnel or an agency.
Purpose :-
To supply essential data for planning or evolution
Proven to be a communication tool for health worker families and other development personnel
Indicates a plane for the future
Assists in research to improve nursing care
The health report shows what are the health problems of the family and what other factors affect the health.
: Principal of Record :-
The nurse should develop methods of self-expression within record writing
Written should be clear.Appropriate. And should be adequate.
The facts written in it should be based on observation, conversation and action.
Selected facts should be relevant to the topic, recording should be neat, complete and uniform.
Documents that are valuable and legal should be handled carefully.
A record should be written as soon as possible after an interview.
A record is a confidential document. Records should be accurately timed, dated and signed.
There should not be any shortcut and unnecessary face within the record.
: Uses of Records and Reports for Person and Family:-
The record serves the patient as a document The record helps to establish continuity of care.
Records provide evidence and support to resolve a legal question.
The record helps in assessing health needs and can also be used as a research and teaching tool.
Uses of records and reports for doctors:-
With the help of records, doctors can provide diagnosis, treatment, evaluation services.
The medical practice indicates how the patient has progressed and what care is needed going forward.
If something happens legally, it protects the doctor and the record can be used for teaching and research.
Uses of Record and Report for Nurse:-
Displays the patient’s health condition
Provides data for what kind of planning to drive further improvement
Serves as a guide for professional growth
It helps to judge the quality and content of the work done.
It becomes a communication tool between staff and other members.
Indicates a plane for the future.
i: ∆Head Nurse’s Responsibilities for Clinical Reports:-
Safeguarding – Hedners are responsible for the safeguarding of patient records. Patient records should not be destroyed or lost. Not a single sheet is to be separated from the complete record and it is kept in a special place where it remains safe.
– Safeguarding the content – There must be a procedure within the hospital to know how to handle this type of legal matter and the keeper is familiar with it. May its records remain confidential.
Completeness- Everything within the record should be complete and identification data should be sufficient within it. The record should also contain vital sign, graphic seat nurse’s observation and nurse’s note which is the responsibility of the head nurse to keep complete.
Responsibility of Nurse’s Notes- The nurse shall use the form of nurse’s note established by the hospital.
: ∆Recording method:-
(1) Narrative Charting – This is a traditional method. It describes the client’s status, intervention, treatment, client’s response to treatment as a story. This method is no longer used as it is time consuming and involves disorganization.
2) Source Oriented Charting– This is a descriptive recording done by each member of the health care team has advantages and disadvantages similar to narrative charting.
(3) Problem Oriented Charting – This method is recorded keeping in mind the client’s problem. And internally all the health care workers identify the problems of the plant and prepare a single list. This method helps in creating a problem oriented care plan.
No progress…
The report can be written on a permanent, weekly, monthly, six-monthly or yearly basis. The report summarizes the services provided by the nurse or agency. A report is a form of analysis of any service. And it is based on records and registers and hence the nurse is necessary to maintain the records daily.
Importance of ∆Report –
A good report preserves the work the nurse has done. and eliminates the need to learn the facts of the investigation within the situation.
The patient gets better care and all the data is available.
A security’s feeling gives a complete report by understanding all the factors within the situation.
Provides efficient help within the management of the ward.
[10:20 am, 6/4/2024] Aanad Bhai: ∆Criteria for a good report:
The report should be made in such a way that the reason behind making the report is fulfilled.
A good report is clear, complete and concise.
So if a record is written, it must contain the identification data, date, time, people, situation and signature of the person writing the report.
The report should be clearly structured so that it is easy to understand.
There is no need to add unnecessary items within a report.
If a report is intended to impress the person in question, it should be clearly expressed and presented and presented in an interesting manner and all important points should be included in it.
[ai: Type of ∆report :-
(1) Oral report:- Oral report is used when the information is to be used immediately, for example this report is given by one nurse to another nurse while the other nurse is planning care for that patient.
(2) Return Report:-
A return report means it is written when it is used by more than one person whose value is permeant, for example we take day-night report, census, interdepartment report, situational, certain events and condition reports. can
i: ∆Majors for writing a good report:-
When one is writing a report, everything should be clear in one’s own mind before writing.
The information and fact within the report should be complete so that the report can be used well.
Accuracy and completeness should be mandatory within a good report.
When the report is written, if the main subject is more than one, it should be a separate report, not all the subjects should be written in one report.
Terminology of the report should be used according to the nature of the report.
If the report is non-technical then it should use short, simple and commonly used words.
If this report is to be given to a professional person, no scientific term should be used in it.
Use of specific words instead of general words within the report…
: ∆Write responsibility of nurse in recording and reporting:-
General Communication – After discharge, the patient has the right to inspect the records himself and can copy the records.
If any kind of information is not written in the report due to the nurse, then it will be considered the nurse’s fault.
-A nurse must keep medical records accurate for proper planning.
-If there are any errors in nursing charting, then to manage them in a correct manner so that there is no mistake in understanding the facts further.
-Adaptive questioning is also known as guided questioning. And the use of this method encourages the patient to communicate fully without interrupting his flow.
-Within this method we can start with a general question and as we progress through the interview, we can make the question more specific.
-Tuning into the patient’s nonverbal communication such as posture, eye contact, facial expression is also considered very important within the nursing assessment.
-Reading and understanding the patient’s nonverbal cues helps the nurse understand the patient more fully, and using therapeutic physical contact (eg, holding the patient’s arm) can facilitate subsequent interviews. .
[10:20 am, 6/4/2024] Aanad Bhai: 4. Empathy Validation and Reassurance:-
-Empathy is an important key to the nursing health office. Which shows how the nurse understands and cares for the patient thus creating a trusting nurse patient relationship.
-Empathic response within the health assessment verbally (saying I understand) or
Non-verbally (by giving a tick if the patient is crying) can be avoided and empathic to ensure that the patient’s feelings are validated and help to reassure him that his emotions are natural and his problem is understood.
: 5. Summarization-
As the interview progresses, summarizing should be done.Note everything the patient says and summarizing shows that you are listening and understanding everything.
6. Transitions and Empowerment –
-A health problem can bring about a filling of anxiety within the patient.
-This should be used during the health history to ease the patient’s fears and tell them what might happen next.
-Patient also feels vulnerable when he is facing a health problem so the patient should be empowered so that the patient gets a positive outcome.
Nursing process
Introduction
Nursing process is a modified form of scientific method that helps the nursing profession in assessing the patient’s needs and creating a course of action that solves the patient’s problem. .
The nursing process is a rational problem solving framework based on professional nursing practice.
Nursing care is delivered through an organized and systemic approach within the nursing process, which increases the probability of a positive outcome for the patient.
List out step of nursing process:-
assessment
Diagnosis
Planing
Implementation
Evaluation
: Write down the benefit of nursing process:-
The nursing process helps us to plan and provide the care we need in an orderly and systematic method.
The nursing process enhances nursing efficiency by standardizing nursing practice.
Documentation of care is facilitated by the nursing process.
The nursing process provides a unity of language for the nursing profession.
The nursing process proves to be economical.
The nursing process helps provide continuity of care to the patient and prevents duplication.
List out the purpose of nursing process:–
The nursing process helps the patient to maintain his health.
The nursing process can protect the client from illness.
The health status of the client can be identified through the nursing process.
The nursing process can identify the client’s actual and potential health problems.
The nursing process can determine the client’s priorities.
A specific nursing intervention can be delivered through the nursing process.
It can be seen how effective the care provided is from the nursing process.
– Nursing process can promote recovery.
The nursing process helps to give the client a peaceful death during terminal illness.