GENERAL PATIENT INFORMATION HEALTH HISTORY
Age: 84 Race: Caucasian Sex: Male MS: Divorced Chronic or Previous Health Problems (include date of onset if known):
-Arthritis
-COPD
-Lung dz
-Hypercholesterolemia
-HTN
-Cancer
-Multiple myeloma
-Muscle Cramps
-Thyroid
___________________________________________________
History of current symptoms: Denied any other pain or complications besides his arm Diet: Healthy Heart,
Height: 172.72 cm Weight: 86.18kg Code Status: Full Resuscitation Activity Ordered: Activity as tolerated
Religion: No preference Economic Status: Medicare Activity Possible: Bed rest. Activity as tolerated
Perception of Health/Reason for Admission (pt’s own words): Nutrition: ? PEG Tube PO
“I broke my arm”
Elimination: ? Foley ? Ostomy—Type: Void
I & O schedule:
Admitting Medical Diagnosis:
Syncope, Hypotension, ARI
Wounds/ Wound Care:
No wound care
Previous Surgeries (include date):
-Left heart cardiac 8/11/15
-Coronary arteriography using two caths 8/11/15
-Biopsy of bone marrow 4/16/15
-Eye
-Hernia
-HIp replacement,
-Knee
-Shoulder replacement
-Thyroid
Respiratory: No supplemental O2
? O2 @ ______ L/min via _________________________
? Incentive Spirometer every ___________
? Respiratory Treatments:
-Documented: Albuterol (Albuterol 90 mcg/inh inhalation) – 2 puffs, INH, BID, PRN SOB or wheezing
-Documented: Fluticasone-salmeterol – 1 puff, INH, BID # 60 EA
-Fluticasone-salmeterol (Advair Diskus 250 mcg-50 mg inhalation powder) – 1 puff, Inh-oral disk, INH, BID, Routine
? Ventilator Settings_________________________
Date of Admission: 2/12/17
Surgical Procedures: No surgeries since admission
Date:
Home Medications:
-Aspirin (Aspirin EC 81 mg) = 1 tab(s), oral daily
-Prochlorperazine (Compazine) = 1 tab, oral q 6hr
-Multivitamin with mineralys (PreserVision oral capsule) = 1 cap, oral, BID, presersivion with Lutein
-Fluticasone – Salmeterol – 1 puff, INH, BID, #60 EA
-Calcium-Vitamin D (Calcium 500 + D oral tablet, chewable) – 1 tab chewed BID
-Multivitamin – 1 tab, oral, daily
-Acetaminophen-hydrocodone (Norco 5mg/325mg) – 1 tab, oral, q4hr, PRN for pain
-Omega-3 polyunsaturated fatty acids (omega – 3 polyunsaturated fatty acids 1000 mg oral capsule) – 1,000 mg = 1 cap, oral, once a day (bedtime) #60 cap
-Potassium chloride – 10 mEq, oral daily
-Memantine (Namenda) – 10mg = 1 tab, oral, BID #60 tabs
-Cetirizine (Cetirizine 10 mg oral tab) = 10 mg = 1 tab, oral daily #30 tabs
-Cyanocobalamin (Vita B12 100 mcg oral tablet) – 100 mcg = 1 tab, oral, daily #30 tab
-Levothyroxine (levothyroxine 112 mcg (0.112 mcg) oral tablet) – 112 mcg = 1 tab, oral daily # tab
-Polyethylene glycol 3350 (MiraLax) – 17 gm 1 packet, oral, daily
-Ropinirole (Ropinirole 2 mg oral tablet) – 2 mg = 1 tablet, oral, once a day #270 tab
-Albuterol (Albuterol 90 mcg/inh inhalation) – 2 puffs, INH, BID, PRN SOB or wheezing
-Omeprazole (Prilosec 20 mg oral delayed releases capsule) – 20 mg = 1 cap, oral, daily
-Isosorbide mononitrate – 30 mg, oral, qAM, 0 refill
-Allupurinol (allupurinol 300 mg oral tab) – 300 mg = 1 tab, oral, daily #30 days
-Ferrous sulfate (ferrous sulfate 325 mg (65 mg elemental iron) oral tab) – 1 tab, once a day #270 tabs
-Lisinopril (Lisinopril 10 mg oral tab) – 40 mg, oral daily #30tabs
-Cholecalciferol (Vitamin D3 400 intl units oral tabs)- 400 int unit = 1 tab(s), oral, daily
-Carbamide peroxide otic (Debrox 6.5% otic soln)-5 drops, otic, BID, # 15 mL
-Donepezil (Donepezil 5 mg oral tab) 5mg = 1 tab, oral once a day at bedtime #30 tabs
-Ondansetron (Zofran 8 g oral tab) – 8 mg = 1 tab, oral, q6hr, PRN N/V #9 tabs
-Amlodipine (Amlodipine 10 mg oral tab) – oral daily ? Accuchecks: ? ac & hs ? sliding scale insulin: No accuchecks/sliding scale
Allergies (include symptoms): Bactrim and Codeine
IV: (includes site change date) LAC site due to be changed 02/16/17
Multidisciplinary: Physician, Nurse, RT
Patient Classification:
Class II. INtermediate care, moderately ill, both pt and nurse participate in care
Priority Dx #1:
R/f injury r/t altered LOC secondary to inadequate cerebral blood flow; increased peripheral resistance; increased concentration of lipids in the blood Priority Dx #2:
Ineffective airway clearance r/t increased production of tenacious secretions and retained secretions Priority Dx #3:
Chronic pain r/t to destruction of tissues/bone; degeneration of joint
VS q4 hours Assess for s/s of ineffective airway clearance (ex: abnormal breath sounds; rapid, shallow respirations; dyspnea; cough)
Assess VS q 4 hours (including pain on a 0-10 scale)
Monitor BP and pulse Improve airway patency (encourage hydration 2 to 3 L/day) If pain present, administer acetaminophen-hydrocodone (Norco 5mg/325 mg) – 1 tab,oral, q4hr, PRN for pain
Check O2 Sat Promote bed rest (the pt should assume a comfortable position to promote rest and breathing ex: Semi-Fowler’s position position) Instruct pt to frequently change positions
Check capillary refill Turn pt q 2 hours as ordered to enhance secretion clearance and pulmonary ventilation and perfusion Encourage the use of relaxation techniques including breathing control and guided imagery
Keep bed in low position with side rails up when pt is in bed Instruct and assist pt to deep breathe and cough or “Huff” every 1-2 hours Give ice-cold compress if needed to relieve the pain and swelling during the acute period of arthritis
Keep needed items within reach Administer albuterol (albuterol 90 mcg/inh inhalation aerosol) – 180 mcg = 2 puffs, inH -oral, INH, BID, PRN for SOB or wheezing
Encourage pt to ask for assistance whenever needed Administer fluticasone-salmeterol (Advair Diskus 250 mcg-50 mg, inhalation powder) – 1 puff, inh-oral disk, INH, BID, Routine
Instruct and assist pt to rise and change positions slowly
Instruct pt to wear nonskid socks
STUDENT: _________________________________ UNIT/ROOM #: ______ DATES OF CARE: ___________________ __________ Front sheet/Orders=15 points
Diagnosis
Diagnosis
Diagnosis
Interventions
Interventions
Interventions
Diagnosis
Diagnosis
Diagnosis
Interventions
Interventions
Interventions
Diagnosis
Diagnosis
Diagnosis
Interventions
Interventions
Interventions
Current Orders:
STUDENT: ____________________________________ DATES OF CARE: ________ Med sheets/Labs=15 points________
(Must provide references for each)
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Influenza virus Vaccine (Flu Vaccine) Immunization 0.5 mL, syringe IM As directed At risk for infections could have allergic rxn if allergic to egg protein
Nursing Implications and Interactions: and during administration. Assess previous immunization hx and hx of hypersensitivity
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Fluticasone-Salmeterol (Advair Diskus powder pgs 1105, 347 Corticosteroid – Bronchodilator 250 mcg – 50 mg Oral, inhalation 1 puff, BID Hx of COPD and lung dz and has ARI. Bronchodilates SE: headache
AE: asthma-related death
Nursing Implications and Interactions: Assess lung sounds, pulse and BP before administering. Drug interactions: MAO inhibitors and tricyclic antidepressants, CYP3A4
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Acetaminophen-hydrocodone (Norco 5 mg / 325 mg)
Davis Drug Guide pg 651 Opiod agonists/nonopioid analgesic combinations 5mg/325 mg oral q4hr, PRN for pain Therapeutic: decreases in severity of moderate pain. Suppression of the cough reflex SE: confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea
Nursing Implications and Interactions: Drug interactions: MAO inhibitors, CYP3A4 inhibitors, alcohol, antihistamines, sedative/hypnotics, kava-kava, valerian, skullcap, chamomile
Implications: Assess BP, pulse and respirations before and periodically during administration
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Acetaminophen Davis Drug Guide pg 97 Antipyretics, nonopioid analgesics 1,000 mg oral 2 tabs Antipyretics, analgesia AE: hepatotoxicity; acute generalized exanthema
Nursing Implications and Interactions: Drug interactions: warfarin, alcohol, isoniazid, rifampin, rifabutin, phenytoin, barbiturates and carbamazepine
Implications: assess overall health status and alcohol usage before administering acetaminophen. Assess type and location of pain
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Memantine (Namenda) Davis Drug Guid pg 800-801 Anti-alzheimer’s agent 10 mg oral BID Displaying cognitive decline. Decreased symptoms of dementia/cognitive decline. Dizziness, fatigue, h/a, sedation, HTN, rash, diarrhea, wt gain, urinary frequency, anemia
Nursing Implications and Interactions: Drug interactions: carbonic anhydrase inhibitors, sodium bicarbonate
Implications: Assess cognitive function (memory, attention, reasoning, language, ability to perform simple tasks)
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Cetrizine (Zyrtec) Davis Drug Guide pg 300 – 301 Allergy, cold and cough remedies, antihistamines 10 mg oral daily ARI. Decreased symptoms of histamine excess (sneezing, rhinorrhea, ocular tearing and redness, pruiritus) CNS: dizziness, drowsiness
Nursing Implications and Interactions: Drug interactions: alcohol, opioid analgesics, sedative/hypnotics
Implications: Assess allergy sx, assess lung sounds and character of bronchial secretions
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Methylprednisolone (Medrol) 353 Intermediate-acting corticosteroids 100 mg = 1.6 mL injection, IV As directed suppression of inflammation and modication of the normal immune response SE: depression, euphoria, hypertension, anorexia, nausea, acnes, decrease wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, muscle wasting, osteoporosis, cushingoid appearnace
AE: peptic ulceration, thromboembolism
Nursing Implications and Interactions: Drug interaction: thiazide and loop diuretics or amphotericin B, digoxin, PHenytoin, phenobarbital and rifampin, NSAID, fluoroquinolones, Antacids, ketoconazole, itraconazole
Implications: Assess for adrenal insufficiency
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Diphendramine Davis Drug Guide pg 431 Allergy, Cold and cough remedies, antihistamines, antitussive 12.5 mg = 0.75 mL, IV injection 1 dose as directed ARI. Decreased symptoms of histamine excess (sneezing, rhinorrhea, nasal and ocular pruirtus, ocular tearing and redness, urticaria). Suppression of cough SE: drowsiness, anorexia, dry mouth
Nursing Implications and Interactions: Drug interactions: antihistamines, alcohol, opioid analgesics, sedative/hypnotics, tricyclic antidepressants, quinidine, MAO inhibitor
Implication: Assess frequency and nature of cough, lung sounds, and amount and type of sputum produced
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Levothyroxine (Synthroid) Davis Drug Guide pg 757 Thyoid 125 mcg oral daily Thyroid supplementation in hypothyroidism. Therapeutic: replacement in hypothyroidism to restore normal hormonal balance Can cause angina pectoris, arrhythmias, tachycardia, abdominal cramps
Nursing Implications and Interactions: Drug interactions: warfarin, insulin, oral hypoglycemic agents, estrogen
Implications: assess apical pulse and BP prior to and periodically during therapy. ASsess for tachyarrhythmias and chest pain
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Albuterol pg 116 Davis Drug Guide Bronchodilator 180 mcg = 2 puffs oral inhalation Inh, BID, PRN for SOB or wheezing ARI. Hx of COPD. Bronchodilation SE: nervousness, restlessness, tremor, chest pain, palpitations
AE: Paradoxical bronchospasm
Nursing Implications and Interactions: Drug interactions: adrenergic agents, MAO inhibitors, Beta blockers, digoxin, tricyclic antidepressants, potassium-losing diuretics
Implications: Observe for paradoxical bronchospasm (wheezing)
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Ropinirole (Requip) Davis Drug Guide pg 1099 Dompamine agonists 2 mg oral once a day Decreased tremore and rigidity in Parkinson’s dz. Decreased leg restlessness. SE: dizziness, syncope
AE: sleep attacks
Nursing Implications and Interactions: drug interactions: p450 CYP1A2,, estrogen, phenothiazines, butyrophenones, thioxanthenes or metoclopramide
Implications: Assess pt for drowsiness and sleep attacks. ASsess pt for concomittant medications that have sedating effects or may increase serum ropinirole levels
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Bortezomib (Velcade) Davis Drug Guide pg 229 Proteasome inhibitors 2.2 mg = 0.88 mL Subq Death of rapidly replicating cells, particulary malignant ones SE: fatigue, malaise, weakness, hypotension, anorexia, constipation, diarrhea, nausea, vomiting, anemia, neutropenia, thrombocytopenia, peripheral neuropathy, fever
AE: progressive multifocal leukoencephalopahty, reversible posterior leukoencephalopathy syndrome, liver failure, bleeding
Nursing Implications and Interactions: Drug interactions: antivirals, amiodarone, nitrofuratoin, isoniazid
Implications: Monitor for s/s of RPLS (h/a , seizure, lethargy, confusion, blindness). HTN. Assess for any new s/s that may be suggestive of PML
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Famotidine (Pepcid) Davis Drug Guide 637 Anti-ulcer agent 20 mg = 50 mL IV soln 200 mL/hr, infuse over 15 min Pt on bedrest. Healing and prevention of ulcers. DEcreased sx of gastroesophageal reflux. Decreased secretion of gastric acid. SE: confusion
AE: arrhythmias, agranulocytosis, aplastic anemia
Nursing Implications and Interactions: Drug interactions: Benzodiazepines, chlordiazepoxide, diazepam, beta blockers, caffeine, CCB, carbamazepine, cyclosporine, dofetilide, lidocaine, metronidazole, mexiletine, nefazodone
Implications: Assess for epigastric or abdominal pain and frank or occult blood in teh stool, emesis or gastric aspirate. Monitor CBC with differential periodically during therapy
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Enoxaparin (Lovenox) Davis Drug Guide pg 634 Anticoagulants
Antithrombotics 30 mg = 0.3 mL Sub q injection daily Prevention of clots Common SE: anemia
AE: bleeding
Nursing Implications and Interactions: Drug interactions: warfarin, aspirin, NSAIDs, dpyridamole, clopidogrel, ticlopidine, eptifibatide, tirofiban and thrombolytics
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Ferrous Sulfate (Elemental iron) Davis Drug Guide pg 708 Iron supplements 325 mg (65 mg elemental iron) oral Prevention/treatment of iron deficiency SE: hypotension, nausea, constipation, dark stools, diarrhea, epigastric pain, skin staining
AE: anaphylaxis, seizures
Nursing Implications and Interactions: Drug interactions: tetracyclines, bisphosphonates, fluoroquinolones, levothyroxine, mycophenolate mofetil, penicillamine, levodopa and methyldopa, PPI, ACE inhibitors
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Ondansetron (Zofran) pg 926 Antiemetics Pharmacologic: 5-HT3 antagonists 2 mg/mL IV injection solution q4hr, PRN for N/V Nausea with no vomiting. Decreased incidence and severity of nausea and vomiting following chemotherapy or surgery. SE: h/a, constipation, diarrhea
AE: torsade de pointes
Nursing Implications and Interactions:
Medication generic/trade Classification/
mechanism of action Dose Route Frequency Why the patient is taking this medication Side Effects
Donepezil (ARicept) Davis Drug Guid pg 449 Anti-Alzheimer’s agents 5 mg oral 1 tab daily Displayed some cognitive decline. May temporarily lessen some of the dementia associated with Alzheimer’s dz. Enhances cognition SE: headache, diarrhea, nausea
Nursing Implications and Interactions: Drug interactions: succinylcholine, anticholinergics, bethanechol, NSAIDs, Quinidine and ketoconazole, Rifampin, carbamazepine, dexamethasone, henobarbital and phenytoin
Implication:Assess cognitive function (memore, attention, reasoning, alnguage, ability to perform simple tasks), monitor HR periodically during therapy
lab studies Date Normal Values Patient Values Reason for Abnormal in YOUR patient (with reference)
__
CBC WNL X
RBC
RBC 2/12/17
2/13/17 4.7-6.1
4.7-6.1 (L) 3.62
(L) 3.13 Multiple Myeloma. Pagana pg 442
Multiple Myeloma. Pagana pg 442
Hgb
Hgb 2/12/17
2/13/17 14-18
14-18 (L) 11.9
(L) 10.1 Multiple Myeloma. Pagana pg 284
Multiple Myeloma. Pagana pg 284
Hct
Hct 2/12/17
2/13/17 42-52%
42-52% (L) 35.9
(L) 30.6 Multiple Myeloma. Pagana pg 280
Multiple Myeloma. Pagana pg 280
MCH
MCH 2/12/17
2/13/17 27-31
27-31 (H) 33
(H) 32 Elevated lipid levels. Pagana pg 445
Elevated lipid levels. Pagana pg 445
RDW
RDW 2/12/17
2/13/17 11-14.5%
11-14.5 (H) 16.0
(H) 16.0 Elevated lipid levels. Pagana pg 445
Elevated lipid levels. Pagana pg 445
MPV
MPV 2/12/17
2/13/17 7.4-10.4
7.4-10.4 (L) 6.8
(L) 6.8 Cancer chemo substance. Pagana pg 408
Cancer chemo substance. Pagana pg 408
Mono Abs 2/12/17 100-700 (H) 0.60 Drug therapy.: prednisone. Pagana 532
Lymph Auto 2/13/17 20-40 (L) 20.1 Drug therapy. Pagana pg 530-532
Cardiac testing WNL except
Total CK
Total CK
Total CK
CK MB
CK MB
CK MB 2/12/17
2/13/17
2/13/17
2/12/17
2/13/17
2/13/17 55-170
55-170
55-170
0%
0%
0% Normal 77
Normal 59
Normal 67
Normal 3.50
Normal 2.60
Normal 2.90 Normal
Normal
Normal
Normal
Normal
Normal
Troponin
Troponin
Troponin
Myoglobin
Myoglobin
Myoglobin 2/12/17
2/13/17
2/13/17
2/12/17
2/13/17
2/13/17 < 0.1- 0.03ng/mL
<0.1 - 0.03 ng/mL
< 0.1 - 0.03 ng/mL
< 90%
< 90%
< 90% (L) < 0.02
(L) < 0.02
(L) < 0.02
Normal 102
Normal 64
Normal 56 According to Pagana, normal
According to Pagana, normal
According to Pagana, normal
Normal
Normal
Normal
ABG’s WNL except
No ABG’s
Coagulation study: No coagulation study
Blood C/S: Negative
U/A 2/12/17
Color
Spec gravity
UA BI
Rlt
Urobilogen
Blood
Glu
Ketones
Protein
Nitrate
Leuk Est Yellow
< = 1.005
Neg
6.0
0.2 Eu/dL
Neg
Neg
Ketones
Neg
Neg
Neg
Lab Studies Date Normal Values Patient Values Reason for Abnormal in YOUR patient (with reference)
Chemistry WNL except
Sodium 2/12/17 136 - 145 (L) 133.0 Pagana pg 466 - 467 Deficient dietary intake
BUN
BUN 2/12/17
2/13/17 10-20
10-20 (H) 37
(H) 30 Pagana pg 511 dehydration
Pagana pg 511 Dehydration
Creatinine
Creatinine 2/12/117
2/13/17 0.5-1.2
0.5-1.2 (H) 1.86
(H) 1.73 Pagana pg 191 Dehydration
Pagana pg 191 Dehydration
GFR African American
GFR African American 2/12/17
2/13/17 87-107
87-107 (L) 42
(L) 46 Pagana pg 193 Dehydration
Pagana pg 193 Dehydration
GFR Non African American
GFR Non African American 2/12/17
2/13/17 87-107
87-107 (L) 35
(L) 38 Pagana pg 193 Dehydration
Pagana pg 193 Dehydration
Calcium 2/13/17 9.0 - 10.5 (L) 7.9 Pagana 138 Drug therapy (Albuterol)
Glucose Level 2/12/17 70-100 (H) 124 Pagana pg 256 Corticosteroids
Diagnostic Testing, EKG’s, etc. Date Interpretation
XR Chest 1 View Portable 2/12/17 Stable exam; no acute process
CT Head 2/12/17 Cerebral atrophy & evidence of mild chronic microvascular ischemia, which appear to be stable
NO acute intracranial abnormality
Small amount of fluid inferior in the L mastoid air cells, which may be related to mastoid effusion clinical correlation is necessary to include mastoiditis
U/S Carotid Duplex Comp Bil 2/13/16 NO significant stenosis identified
STUDENT: _________________________________________________ DATES OF CARE: __________________________________
Daily focused assessment of systems using AD Nursing assessment guides. __________ 20 points
CARDIOVASCULAR ENDOCRINE
GENITOURINARY
MUSCULOSKELETAL
RESPIRATORY
INTEGUMENTARY
REPRODUCTIVE Patient’s General Appearance Growth and Development
Patient’s Age: _______
GASTROINTESTINAL Usual Sleep Pattern
Assessment of How Each Developmental Task is Met or Unmet and Summary of resolution
SENSORINEURAL
Activities to Promote Health
_____________________________________
Activities needed to improve health
NURSING DIAGNOSIS, GOALS AND OUTCOME CRITERIA
5 points
Diagnosis:
R/f injury r/t altered LOC secondary to inadequate cerebral blood flow; increased peripheral resistance; increased concentration of lipids in the blood
Goal: TPW not become injured AEB no new bruises, broken bones or bleeding
Outcome:
NURSING INTERVENTIONS
Individualized and Applicable in order of priority
10 points
PATHOPHYSIOLOGY to support Nursing Diagnosis and Intervention
(must paraphrase and reference)
15 points
EVALUATION OF INTERVENTIONS AND ACHIEVEMENT OF GOALS
10 points
nURSING DIAGNOSIS, GOALS AND OUTCOME CRITERIA
5 points
Chronic pain r/t to destruction of tissues/bone; degeneration of joint
NURSING INTERVENTIONS
Individualized and Applicable in order of priority
10 points
HOPHYSIOLOGY to support Nursing Diagnosis and Intervention
(must paraphrase and reference)
15 points
ATION OF INTERVENTIONS AND ACHIEVEMENT OF GOALS
10 points
STUDENT: ________ DATES OF CARE: _______
INTERPERSONAL INTERACTION ________10 points
Describe the time spent with your patient/family. Describe the predominant mood of your patient/family (support your findings with facial expressions, motor behavior and an example of words used to illustrate the mood). Also identify underlying themes that preoccupied the patient’s/family’s thoughts noted during the interaction.
Describe and give examples of the communication patterns of the patient with significant others and other health team members. (Spontaneous, logical, relaxed, forced, pressured, tangential or circumstantial?) Did you assess any abnormalities such as loose associations, neologisms?
Identify your patient’s/family’s significant stressors. Describe how you assessed and responded verbally and non-verbally to stressors and concerns. How did the patient/family react to your attempts to communicate? How did they respond to the primary nurse assigned? Was there a difference? What do you suppose were some of the reasons for the different responses?
Identify the barriers and personal biases that affected or could have affected your nurse- patient relationship.
What could you have said or done differently to enhance therapeutic communication and promote a better nurse patient relationship with this patient/family?
