Chapter 7
Communication
and Documentation
Aphasia—Loss of or impairment in ability to communi-
cate through speech, writing, or gestures.
Channel—Vehicle used to convey a message.
Communication—Dynamic, purposeful, reciprocal
process of sending and/or receiving a message.
Expressive aphasia—Inability to formulate and/or send
a message.
Feedback—Response from the receiver to the sender.
Message—Information communicated.
Nonverbal communication—Use of facial expression or
other body language to convey a message.
Plan of care—Written communication of strategies that
should be implemented to meet patient needs.
Receiver—Person who acquires a message.
Receptive aphasia—Inability to understand communi-
cated information.
Sender—Person who conveys a message.
Verbal communication—Use of spoken or written
words to communicate a message.
KEY TERMS
I. Communication
Communication is a dynamic, purposeful, reciprocal
process of sending and/or receiving a message. The need
to communicate is universal because it is the way people
convey and fulfill needs.
A. Concepts About Communication
1. All verbal and nonverbal communication transmits
meaning.
2. Communication is a learned process.
3. Communication can occur within the self (intrap-
ersonal); between two people (interpersonal); or
when sending a message to or communicating
within a group, such as with public speaking, small
self-help and social groups, and group therapy.
4. Recurring ideas and thoughts (themes) communi-
cated during an interaction provide insight to a
patient’s feelings.
5. A trusting relationship is basic to effective com-
munication.
6. A patient’s degree of expression (emotional affect)
reflects the patient’s mood.
7. Humor is highly subjective; it can mean different
things to different people.
8. Patients have a potential for growth as a result of
verbal and nonverbal communication.
9. Previous patterns of communication can become
inadequate when one is ill or under stress.
10. Communication is confidential information and
should be shared only with health team members.
B. Elements of Communication
1. Sender (encoder/source): Person who conveys a
message.
2. Message: Information communicated; includes
language, words, voice intonation, and gestures.
3. Channel (mode): Vehicle used to convey a mes-
sage; includes written, oral, and touch.
4. Receiver (decoder): Person who acquires a message.
5. Feedback (response): Response from the receiver
to the sender.
C. Factors Affecting the Communication Process
1. Attitudes, values, beliefs, and experiences.
2. Culture, education, and language.
3. Developmental level.
a. The very young are concrete thinkers and have
little or no experience.
b. Adults are more abstract thinkers.
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130 Unit II Psychosociocultural Nursing Care
c. Older adults may have vision and hearing loss
that interferes with communication.
4. Gender.
a. Males and females generally communicate
differently from an early age.
b. Females seek intimacy and validation and
reduce differences; boys use language to negoti-
ate status and establish independence.
c. Differences are changing as gender roles
become less distinct.
5. Authority one ascribes to a role (e.g., some see
nurses as authority figures, whereas others see
nurses as servants).
6. Ineffective perception or selective inattention: May
distort a message.
D. Barriers to Communication
1. Unwillingness to listen to another point of view.
2. Physical factors, such as an uncomfortable envi-
ronment (e.g., too hot or too cold), excessive
noise, or distractions.
3. Adaptation to disease, such as impaired ability to
communicate through speech, writing, or signs
because of brain dysfunction (e.g., receptive or
expressive aphasia); impaired ability to say words
(dysarthria); impaired cognition (e.g., dementia
or delirium); oral problems; fatigue; and pain.
4. Treatment related factors, such as laryngectomy,
or artificial airways, such as tracheostomy or
endotracheal tube.
5. Psychological factors, such as lack of privacy,
anxiety, and fear.
E. Phases of the Communication Process
1. Preinteraction phase.
a. This phase occurs before meeting the patient.
b. The nurse gathers information about the patient.
2. Orientation phase.
a. Initially, the nurse is in the stranger role.
b. The nurse meets a patient and begins to estab-
lish a relationship of rapport and trust.
c. Introductions and initial exchange of informa-
tion occurs.
d. The purpose of the visit is explained, roles are
clarified, and an agreement or contract about
the relationship may be formulated.
e. The termination phase is initiated in this phase.
3. Working phase.
a. Most communication occurs during this phase.
b. This phase is the active part of the relationship.
c. The nurse and patient work together to address
patient needs, feelings are shared, caring is
demonstrated, and mutual respect is maintained.
d. The nurse may function as caregiver, counselor,
teacher, resource person, and so on.
e. The nurse motivates a patient by identifying
progress and supporting movement toward
independence.
f. Anxiety may increase during this phase as
the patient may need to learn new adaptive
behaviors.
g. Preparation for the termination phase
continues.
4. Termination phase.
a. Actual termination occurs at the conclusion of
a relationship.
b. Termination occurs at discharge, at the end of a
shift, or when the goals of the relationship are
achieved.
c. Goals and objectives are summarized, adap-
tive behavior is reinforced, and additional
resources available are arranged for the
patient.
d. Some patients become emotional during this
phase because they feel angry, rejected, or fear-
ful of leaving a safe environment; the nurse
needs to address these feelings.
F. Modes of Communication
1. Verbal communication: Uses spoken or written
words to communicate a message.
a. Characteristics.
(1) Clarity: Simple words and sentence struc-
ture are better understood.
(2) Intonation: Reflects feeling behind words;
loud or soft volume, cadence, and pitch can
impart a message, such as anger, excite-
ment, sarcasm, and fear.
(3) Pacing: Speed, rhythm, and patterns of
delivery can convey anxiety, indifference,
and attention; pace must be fast enough to
maintain interest, but slow enough for
receiver to decode the message.
(4) Relevance: Message needs to be conveyed
when the receiver is ready and able to
receive the message; information has to
be important to the patient.
b. Nursing care.
(1) Build a therapeutic relationship.
(a) Place oneself in the patient’s place men-
tally and emotionally (empathy).
(b) Acknowledge the patient’s individuality;
be flexible when meeting needs.
(c) Address the patient by name; avoid
using terms of endearment, such as
“grandma” and “honey.”
(d) Respect values and beliefs.
(e) Provide privacy.
(f) Maintain credibility and genuineness; be
truthful, respond to needs promptly, and
follow through on promises.
(2) Let the patient take the lead in the commu-
nication process.
(3) Use simple words and sentence structures;
keep messages brief.
(4) Ensure intonation and pace of words
convey professional confidence, respect,
interest, and acceptance of the patient.
(5) Ensure that message is relevant and a prior-
ity for the patient.
(6) Use humor carefully; although it may
lighten the mood, it can be misunderstood
and offend a patient.
(7) Validate congruence between verbal messages
and nonverbal behavior.
2. Nonverbal communication: Message that is sent
and received without use of spoken or written
words; involves use of body language; may be more
accurate than verbal communication because it is
less consciously controlled.
a. Characteristics.
(1) Facial expression: Can convey meaning or
mask emotions; some expressions are uni-
versal, such as a smile (happiness) or a
frown (displeasure); can be subtle, such as
raising the eyebrows.
(2) Gestures: Emphasize spoken word; some
have same meaning regardless of culture,
such as waving indicates hello or goodbye;
different gestures may have similar meanings,
such as shaking a fist versus cold, stillness
when angry; shaking the head “yes” may
indicate the message has been received even
though message is not understood.
(3) Eye contact: In Western cultures, indicates
interest and attention, whereas downcast
eyes may indicate low self-esteem, power-
lessness, and sadness; however, in some
cultures, downcast eyes show respect.
(4) Posture and gait: Erect posture, head held
up with a rapid gait indicates well-being
and confidence; slumped, slow, shuffling
gait with head held low indicates illness,
depression, or impaired self-esteem; cross-
ing legs and arms indicates a defensive
posture.
(5) Touch: Generally conveys caring, concern,
encouragement; some patients do not like
to be touched, and touching is unacceptable
in some cultures (e.g., only relatives can
touch an orthodox Jewish man).
(6) Territoriality and space: People have a phys-
ical zone around the body that is culturally
and individually defined.
(a) Intimate: 0 to 18 inches; used for provid-
ing nursing care or emotional support,
such as hygiene and hand holding.
(b) Personal: 1.5 to 4 feet; used for therapeu-
tic communication, such as nurse-patient
conversation, counseling, and teaching.
Chapter 7 Communication and Documentation 131
(c) Social and public: 4 feet and beyond;
used when performing more formal
interventions, such as making rounds,
teaching a class, or facilitating a group.
b. Nursing care.
(1) Be aware of a patient’s culture and its
impact on nonverbal communication.
(2) Demonstrate behavior that supports a
therapeutic relationship, such as eye con-
tact, caring facial expression, unhurried
behavior, and open posture.
(3) Validate the meaning of body language to
ensure messages are received as intended.
(4) Validate the meaning of body language that is
not congruent with the spoken word.
(5) Use touch cautiously so as not offend the
patient.
(6) Explain what is going to be done and why
before entering a patient’s personal space;
entering personal space may be perceived as
a violation of a patient’s territory and the
patient may feel uncomfortable, threatened,
or anxious.
(7) Knock before entering a patient’s room, and
ask permission before entering a patient’s
closet or bedside drawer.
(8) Close the door, pull the curtain, or drape
the patient when engaging in nursing care
that requires privacy because doing so
conveys respect.
II. Therapeutic Versus Nontherapeutic
Communication
Therapeutic communication is interaction between a
nurse and a patient in which the nurse focuses on the feel-
ings, concerns, needs, and/or objectives of the patient.
Nurses must develop a repertoire of verbal and nonverbal
techniques that can be used to facilitate therapeutic com-
munication as well as be aware of the various attitudes and
approaches that can hinder communication. The thera-
peutic use of self is the most valuable tool that nurses have
to facilitate therapeutic communication and ultimately de-
velop an effective nurse-patient relationship.
A. Therapeutic Communication: See Table 7.1
B. Nontherapeutic Communication: See Table 7.2
III. Nursing Care for Patients With Special
Communication Needs
A patient’s physical, emotional, or cultural status may result
in a diminished or absent ability to receive, process, or send
a message. When impaired communication occurs between
a patient and a nurse, it is the nurse’s responsibility to iden-
tify what is interfering with the communication process.
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132 Unit II Psychosociocultural Nursing Care
Table 7.1 Therapeutic Communication Techniques and Related Nursing Care
Therapeutic Communication Technique Related Nursing Care
Silence
• Provides time for the patient to process what was said, reflect,
and articulate a response.
• Encourages the patient to initiate or continue a conversation.
Offering Self
• Indicates a nurse’s attention and interest without expectations.
Open-Ended Questions
• Allows the patient to control the direction of the conversation
to an area of concern.
Direct Questions
• Facilitates collection of objective information.
• May interfere with exploration of feelings because they may
be too blunt and threatening.
Paraphrasing
• Encourages further discussion by repeating content in same or
similar words.
• Conveys that the message was understood.
• Allows the patient to hear what he or she said.
Reflection
• Encourages further discussion by focusing on emotional themes
and feelings.
• Indicates active listening.
• Helps the patient to identify emotional themes and feelings.
Clarifying
• Encourages elaboration on unclear messages.
• Ensures that the message is understood as intended; minimizes
misunderstanding.
Focusing
• Directs conversation to areas of concern; targets discussion to
key points.
• Encourages the patient to expand on an idea, thought, or
feeling.
Validating
• Identifies and supports what the patient feels or believes.
• Demonstrates respect for the patient.
• Demonstrates empathy.
Touch
• Communicates caring, concern, and encouragement.
Summarizing
• Highlights important points in a conversation, such as progress
made and tasks that may still need to be accomplished.
• Maintain an open posture.
• Maintain an unhurried manner.
• Maintain an open posture.
• Maintain an unhurried manner.
• Example: Say, “I will sit with you for a while.”
• Ask questions that require more than one-word answers and
invite a more detailed response.
• Example: “Tell me about how you have been managing your
illness.”
• Keep questions short and simple.
• Example: “Have you received the pneumococcal (PVC) vaccine?”
• Listen attentively.
• Focus on content.
• Example: The patient says, “When I’m discharged, I might
have a hard time because I live alone.” The nurse responds,
“You sound concerned about how you are going to manage.”
• Listen attentively.
• Focus on feelings rather than content.
• Example: The patient says, “I don’t understand how I had a
heart attack. I don’t smoke or eat fatty foods, and I exercise
regularly.” The nurse responds, “It must be frustrating to have
a heart attack when you did everything right.”
• Be nonjudgmental; do not place responsibility for lack of
understanding on the patient.
• Example: “I don’t understand what you mean when you say
that your pain feels like melting lava.”
• Focus on the priority topic of concern.
• Example: “Earlier you mentioned that you are having a prob-
lem with recurrent diarrhea.”
• Maintain a nonjudgmental, empathetic demeanor.
• Example: “I can understand how difficult it must be to wait
5 days for a biopsy result.”
• Use touch cautiously because some patients prefer not to be
touched, touch can be misunderstood, and touch invades a
person’s intimate space.
• Examples: Hold a patient’s hand or place an arm around a pa-
tient’s shoulder.
• Review just the most important points.
• Provide a summary in writing when appropriate.
• Example: “Let’s review what we accomplished today.”
Once the cause has been identified, the nurse can formulate
an individualized plan to promote communication.
A. Commonalities of Nursing Care
1. Reduce noise and minimize distractions.
2. Stand in front of the patient while making eye
contact.
3. Be alert to nonverbal cues and behavior.
4. Explain everything that is going to be done and
the reasons why using simple words and sentence
structures.
5. Give the patient adequate time to formulate a mes-
sage and respond to a message.
Chapter 7 Communication and Documentation 133
Table 7.2 Nontherapeutic Communication and Preventive Nursing Care
Nontherapeutic Communication Preventive Nursing Care
Being Judgmental
• Imposes the nurse’s opinions, values, beliefs, and standards on
the patient.
• Demonstrates lack of respect for the patient.
Using Medical Jargon
• Confuses patients.
• Communicates that the nurse is not interested enough to make
information understandable.
• Demonstrates a demeanor of superiority and arrogance.
Using Ridicule or Sarcasm
• Conveys a hostile attitude through words or tone of voice.
Using Probing Questions
• Invades privacy because it attempts to obtain information to
satisfy one’s curiosity.
• Pressures the patient to discuss topics before he or she is ready.
Focusing on Self
• Demonstrates lack of interest in the patient.
• Demonstrates an attitude of self-importance and egocentricity.
Stereotyping
• Devalues patient uniqueness and individuality.
• Demonstrates opinions either blatantly or subtly, such as men
who cry are not manly, and patients who are health-care
professionals do not need health teaching.
Changing the Subject
• Indicates lack of interest in the patient’s concerns or feelings.
• Reflects that the nurse feels uncomfortable talking about the
topic.
• Cuts off communication when the patient may be ready to
discuss an emotionally charged topic.
Providing False Reassurance
• Minimizes the patient’s concerns.
• Violates trust.
Minimizing Feelings
• Devalues the validity of the patient’s feelings.
Giving Advise
• Bases responses on one’s own values and beliefs rather than
on what is important to the patient.
• Limits the patient’s right to be a partner in problem-solving.
• Supports dependence and is controlling.
Using Clichés, Colloquialisms, and Slang
• Trivializes the patient’s concerns.
• Causes misunderstanding.
Using Terms of Endearment
• Demonstrates lack of respect.
• Reflects an unprofessional demeanor.
Responding Defensively by the Nurse
• Demonstrates the nurse’s attempt to protect the self rather
than focus on the patient’s concerns; defensive responses
usually are precipitated by patients who are angry, demanding,
or critical.
• Minimizes the patient’s concerns.
• Focuses on content rather than feelings.
• Be aware of own values, beliefs, standards, and opinions and
do not impose them on others.
• Use words that demonstrate acceptance.
• Maintain an empathetic demeanor.
• Use words that can be understood; avoid use of medical
jargon, such as medical terminology, acronyms, and slang.
• Offer opportunities to ask questions; answer all questions to
the patient’s satisfaction.
• Seek feedback to ensure understanding.
• Avoid cutting, caustic, and hostile remarks.
• Avoid ridicule.
• Ask questions based on the patient’s needs, not curiosity.
• Use open-ended questions.
• Remember that the patient is the center of the health team.
• Focus on the patient’s needs and not self-needs.
• Assess own beliefs, such as stereotypes, biases, and preju-
dices, and ensure that they do not affect professional
relationships.
• Accept each patient as unique.
• Identify health-care topics that cause anxiety within one’s
self and seek education or counseling to become therapeutic
in the health-care role.
• Listen attentively.
• Focus on the patient’s concerns.
• Answer questions truthfully; base reassurance on facts.
• Address underlying concerns.
• Use the communication technique of reflection.
• Address feelings.
• Assist the patient to explore his or her own feelings, con-
cerns, opinions, and options.
• Assist the patient to use critical thinking to arrive at a
conclusion.
• Use words that the patient can understand.
• Avoid comments that may have ambiguous meanings or
multiple interpretations.
• Call the patient by his or her name.
• Avoid use of intimate names (e.g., honey, dear, sweetie, mom,
or pop).
• Identify the underlying cause of the patient’s behavior;
patients’ angry, demanding, or critical responses are attempts
to protect the self; all behavior has meaning.
• Focus on the patient’s feelings.
• Involve the patient in identifying a resolution, such as, “I am
sorry that I did not meet your expectations. What can I do
now to help you?”
Continued
134 Unit II Psychosociocultural Nursing Care
Table 7.2 Nontherapeutic Communication and Preventive Nursing Care—cont’d
Nontherapeutic Communication Preventive Nursing Care
Challenging the Patient
• Requires the patient to defend his or her feelings or point
of view.
• Ignores the patient’s feelings and rights.
• Causes the patient to abandon a coping mechanism that
may be temporarily therapeutic.
Asking “How” or “Why”
• Threatens or intimidates the patient.
• May leave the patient unsure how to answer the question.
Asking Too Many Questions
• Overwhelms the patient emotionally and may invade the
patient’s privacy or precipitate feelings of “being interrogated.”
• Overwhelms the patient physically.
Engaging in Nonprofessional Involvement
• Oversteps boundaries of the therapeutic nurse-patient
relationship.
• Befriends the patient, but actually abandons the patient
because the nurse is unable to fulfill professional role.
• Accept the patient’s right to have his or her own feelings,
beliefs, and point of view.
• Support the patient’s coping mechanisms, unless they are
destructive to self or others; abandoning a coping mecha-
nism can leave a patient defenseless.
• Use open-ended questions.
• Explore issues with the patient so that he or she can develop
insight and come to own conclusions about “how” or “why.”
• Assess the patient’s physical and emotional stamina to
engage in data collection.
• Use several shorter sessions to collect data.
• Maintain a professional relationship with the patient as
the center of the health team; avoid personal and social
relationships.
• Minimize self-disclosure; use it judiciously.
• Explain the nurse-patient relationship, and set limits if
necessary.
6. Seek feedback to ensure that the message is re-
ceived as intended.
7. Repeat a message using different words if the mes-
sage was not understood.
B. Patients Who Are Angry
1. Assess for the cause of anger because all behavior
has meaning.
2. Assess for verbal and nonverbal signs of escalating
aggression, such as a loud voice, clenched fist and
jaw, narrowed eyes, and physical agitation.
3. Model acceptable behaviors, such as keeping a
calm voice with a normal volume, tone, and pace.
4. Validate the patient’s feelings.
5. Avoid touching the patient because it may be
perceived as a threat.
6. Do not turn your back to an angry patient or avert your
eyes away from the patient; position yourself between
the patient and the door.
C. Patients Who Have Aphasia
1. Assess the patient’s ability to communicate
through speech, writing, or alternate means of
communication, such as gestures, a picture board,
and computer programs.
2. Promote communication when the patient has
an inability to formulate and/or send a message
(expressive aphasia).
a. Use questions that require a one-word answer
or a short response.
b. Give the patient ample time to formulate a
message; do not complete sentences for the
patient.
c. Use alternate means of communication, such
as picture cards, blinking the eyes once for
yes and twice for no, a computer, a puff-
activated communication device, or a voice
synthesizer.
3. Promote communication when the patient has an
inability to understand communicated informa-
tion (receptive aphasia).
a. Use simple words and sentences; vary words
when repeating a message.
b. Augment verbal messages with gestures and
facial expressions.
c. Augment verbal communication with picture
cards or objects, such as holding up a cup of
water to encourage fluid intake.
D. Patients Who Are Confused
1. Use short sentences and convey concrete ideas.
2. Speak slowly.
3. Use questions that require a one-word answer or
a short response.
4. Break down instructions into simple steps.
5. Augment verbal communication with picture
cards or objects, such as holding up a comb to
indicate the need for hair care.
E. Patients Who Are Hearing Impaired
1. Ensure that the patient is wearing a hearing aid, if
available; ensure that a hearing aid is functioning,
is inserted properly, and is cleaned and stored with
a label.
2. Stand on the patient’s side with more acute
hearing; speak at a normal pace using a low
tone because high-pitched sounds are harder
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Chapter 7 Communication and Documentation 135
to hear; use a slightly louder volume, but do
not yell.
3. Face the patient, enunciate words (without exag-
geration), and to facilitate lip reading avoid chew-
ing gum or holding a hand in front of the mouth
when speaking.
4. Use gestures and facial expression to augment
verbal communicate.
5. Determine whether the patient knows sign lan-
guage, and seek the assistance of sign-language
specialists if applicable.
6. Provide writing materials to support communica-
tion if the patient is able to write and is literate.
F. Patients Who Are Unresponsive
1. Assume that the patient’s hearing is intact because
hearing is believed to be the last sense lost before
death. Never talk about a patient or others in front of
the patient thinking that the patient cannot hear.
2. Talk to the patient in a normal volume, tone,
and pace.
3. Explain what you are going to do and the reasons
why before touching a patient.
G. Patients Who Are Visually Impaired
1. Provide adequate lighting.
2. Speak in a normal volume because the patient is
not hearing impaired.
3. Explain what you are going to do if you have to
touch the patient and seek permission first.
4. Orient the patient to surroundings, such as furni-
ture in room and food on a plate using a clock as
a format (e.g., meat is at 12, green beans at 3, pota-
toes at 6).
H. Patients Who Do Not Speak English
1. Seek the help of a professional interpreter fluent in
the patient’s language (e.g., use a telephone service
that provides translation services); avoid the use of
non-educated translators or family members
because inaccuracies may occur (inadvertently or
deliberately) as well as confidentiality may be
jeopardized.
2. Use a translation book that presents common
questions and answers in the nurse’s and patient’s
language.
3. Use pictures, body language, and environmental
cues to communicate until an interpreter is
available.
I. Patients With a Physical Barrier (e.g., endotracheal
tube, laryngectomy)
1. Encourage the patient to use eye blinks, hand
squeeze, writing tools, such as a magic slate, flash
cards or pictures, or a communication board to
communicate.
2. Reinforce and praise efforts to communicate.
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IV. Types of Interactions Between the Nurse
and Other Health-Care Team Members
Information about patients must be communicated
between nurses and among nurses and other members of
the health team, including patients and their families.
Whether the interaction is verbal or written, a systematic
approach is preferred so that the message is clearly, con-
cisely, and accurately transmitted and received.
A. Systematic Approach to Communication
1. Framework to facilitate thorough communication
among health-care professionals to provide a cul-
ture of safety for the patient.
2. Current movement occurring in the health-care
community toward setting standards related to
interdisciplinary communication (e.g., the Joint
Commission is requiring that a systematic
approach be used during nursing change of shift
reports and when a nurse seeks a telephone order
from a primary health-care provider).
3. Example: SBAR.
a. Situation: Identify self, title, facility; identify
patient, date of birth, gender; reason for
collaboration.
b. Background: Patient’s present issue, relevant
medical history, summary of background.
c. Assessment: Vital signs and clinical indicators
outside expected range, severity of patient issue,
nurse’s clinical impression.
d. Recommendation: Explain what is required
and urgency of what is required; make
suggestions.
MAKING THE CONNECTION
Systematic Approach to Communication
and Clinical Practice:
A patient with no previous history of acute or chronic
health problems is admitted to a hospital for surgical
removal of a mass in the ascending colon. After an
uneventful recovery in the postanesthesia care unit, the
patient is transferred to a surgical unit. The patient is
receiving a patient-controlled analgesia intravenous infu-
sion containing morphine. In addition to the basal dose of
1 mg/hour, the patient is allowed a 0.2 mg on-demand
dose with a lock-out interval of 10 minutes. The patient can
self-administer six 0.2 mg doses per hour, for a total of
1.2 mg/hour, with a maximum dose of 8.8 mg in 4 hours.
As the postoperative period progresses, the nurse identifies
that the patient’s personal pain rating scale has increased
from a range of 2 to 3 to a range of 4 to 5 and the PCA
pump history indicates that the patient has been pressing
the button every 5 minutes in the last hour. The nurse
Continued
interventions and patient responses, dependent
and independent nursing interventions to be
implemented, report of patients who are off the
unit temporarily (includes purpose, when they are
expected to return, and nursing care that is antici-
pated), and patients who have been admitted,
transferred, or discharged.
C. Telephone Reports
1. Method by which critical information, such as
laboratory test results, may be communicated
to the unit.
2. Method by which nurses can report a change in a
patient’s condition to a primary health-care
provider.
3. Require the nurse to identify self by name and
title, state relationship with the patient, and con-
cisely and accurately report the patient’s condi-
tion, including vital signs, any clinical findings,
and any intervention already performed for the
patient.
D. Transfer and Discharge Reports
1. Concisely summarize all pertinent data about
a patient that are needed to implement immedi-
ate care.
2. Include, but are not limited to, discharge from
the postanesthesia care unit (PACU); discharge to
another facility, such as a nursing home or reha-
bilitation center; discharge to another service
within the facility; and discharge from the hospital
to home.
E. Reports to Family Members
1. Provide a progress report to designated family
members; the patient gives legal consent to disclose
confidential information to a designated person.
2. A code word, functioning as a PIN number, is re-
quired from a caller before a nurse can give infor-
mation over the telephone.
DID YOU KNOW?
Nurses legally are not permitted to acknowledge
that a person is admitted to a facility. Acknowledg-
ing a patient’s presence without the patient’s consent
violates the patient’s right to confidentiality and
Health Insurance Portability and Accountability Act
(HIPAA) laws.
F. Nursing and Interdisciplinary Team Conferences
1. Nurses and other health team members meet
to discuss a patient’s needs and coordinate a
patient’s care.
2. Promote critical thinking from a multidisciplinary
perspective.
G. Incident Reports
1. Are required in response to any occurrence out of
the ordinary that results in or is likely to result in
harm to a patient, employee, or visitor.
136 Unit II Psychosociocultural Nursing Care
MAKING THE CONNECTION—cont’d
assesses the patient. The patient’s vital signs are: T—99.6°F;
P—92 beats/minute and regular; R—22 breaths/minute,
regular, and shallow; BP—134/88 mm Hg. The patient states
that the incisional pain is sharp and rates it as a 7 on a scale
of 0 to 10. The patient is lying in one position, has clenched
fists, and is exhibiting a facial grimace. The patient’s oxygen
saturation is 96 percent, the urinary catheter is draining an
adequate amount of clear yellow urine, and the dressing is
dry and intact. The nurse concludes that the patient’s anal-
gesic prescription is inadequate to relieve the patient’s pain
and places a phone call to the patient’s primary health-care
provider. The nurse uses the SBAR format to provide a sys-
tematic approach when communicating with the primary
health-care provider.
Situation: Hello, this is Ms. Jones. I am a registered nurse
from Longview Medical Center. I am caring for Mr. Smith,
who was born April 5, 1939, and I am calling about his
patient-controlled analgesia (PCA).
Background: Mr. Smith had no acute or chronic health prob-
lems prior to this admission. He had surgery at 0800 this
morning for resection of a tumor in his ascending colon. His
PCA prescription is morphine basal dose of 1 mg/ hour and
he is allowed a 0.2 mg on-demand dose with a lock-out
interval of 10 minutes. The patient can self-administer six
0.2 mg doses per hour, for a total of 1.2 mg/hour, with a max-
imum dose of 8.8 mg in 4 hours. In the last hour, Mr. Smith
has pushed the trigger of the PCA pump every 5 minutes.
Assessment: Mr. Smith states that his pain is a 7 on a scale
of 0 to 10. His vital signs are T—99.6°F; P—92 beats/minute
and regular; R—22 breaths/minute, regular, and shallow;
BP—134/88 mm Hg. He is lying in one position, has
clenched fists, and is exhibiting a facial grimace. The
patient’s oxygen saturation is 96 percent, the urinary
catheter is draining an adequate amount of clear yellow
urine, and the dressing is dry and intact. I think that
Mr. Smith is in excessive pain and the prescribed dose of
morphine is inadequate to control his pain.
Recommendation: Mr. Smith has been in excessive pain
for an hour and it is important to adjust the morphine
prescription. Could you please increase the basal dose,
increase the on-demand dose, or shorten the lock-out
time?
B. Change of Shift Report
1. Given by a nurse who is finishing a shift to a nurse
who is responsible for continuing care of the
patient.
2. May be verbal, written, or audiotaped; may
include walking rounds where two or more nurses
visit the patient as part of the report.
3. Includes basic data about the patient, current
assessment of the patient’s health status, rece