Therapeutic Communication

1. Respond with feeling tone

2. Provide information

3. Do not ask "why"

4. No yes/no questions

5. Do not focus on the nurse

6. Do not explore

7. Never say "dont worry"

Therapeutic Communication

We communicate therapeutically with everyone in NCLEX land-> think "listen, reflect, provide info or ask open ended questions" listen to your client=what is the topic? (what do they want to talk about) and reflect on that topic

Who do you see FIRST

-The most unstable

(Who is going to die first)

-Compare each patient to the next; eliminate the more stable of the patients

-Consider:

ABC

Acute vs Chronic

Expected vs Unexpected

Actual vs Potential

-Eliminate each stable patient until you have most unstable

Assignment Strategy

RN: assessment, teaching, evalution

i.e. admit, discharge, change in condition, etc

LPN: stable patients with predictable outcomes

i.e. gather data, recognize norms, know sterile procedures

NAP: standard unchanging procedures

i.e VS, o2 sats, ADLs, blood glucose, etc (remember, if you would allow the patient to do it at home safety, most likely it would be safe for the NAP to do)

Think: it is a risk for aspiration? is it safe?

Decision Tree

Step 1: Topic

Step 2: Gathering Data vs Implementation

Step 3: Physical vs Psychosocial

Step 4: ABCs

Step 5: Outcome

-All outcomes must be safe and effective

ABC

Airway

Breathing

Circulation

Triage

Actual vs Potential

Acute vs Chronic

Expected vs Unexpected

ABCs

Decide if a question is...

Priority or Evaluation

Priority Questions

BEST, MOST, FIRST

-Use all 5 steps of the tree

-If it is a statement, even if is has priority words in it, it could still be an evaluation, but if it is an action, it is a priority

When gathering data

Decide if it is NEED to know or GOOD to know

If unsure if it is a priority or evaluation question...

Just go down the decision tree anyway

When a patient is using crutches..

they should come to about 1-2 in below axillary

5 Ps

Perastesia (no feeling)

Pulselessness (no pulse)

Pallor (pale)

Paralysis (cant move)

-Added by kaplan instructor

Poikilothermia (feels cool to touch)

Mantoux test

TB skin test

People before..

Paperwork

Dialysis

Feel the thrill

Hypercalcemia

Can damage CNS

(8.5-10.5)

Contraindications for birth control

Circulatory issues

Pay attention to extreme words

ALL, NEVER, ALWAYS, INSISTS, IMMEDIATELY, SUDDEN, REQUIRED, NONE, MOST, ONLY, etc

Mongolian spots

Bluish-black pigmented skin on an african american infant

Always chart...

detailed observations (paint the oncoming nurse a vivid picture)

What happens when a pregnant female lays on her back?

It compresses the vena cava flat and can cause her to faint (feel dizzy and nauseous at first)

Should a pregnant women receive live virus injections?

No, it should be done after baby is born and the women should not get pregnant for atleast 4 weeks after

Elderly+Antibiotics+Foul smelling stools=?

C. Diff= highly contagious Gi infection.

Elderly clients are at a greater risk for C. Diff related to atrophy (shrinks) of thier GI cells. Antibiotics destroy normal flora = C. Diff has a party and grows in the elderly population

Fires

RACE: Rescue, Alarm, Contain, Extinguish

Environmental temp..

can change skin color

When using crutches

Think up with the bad and down with the good

When going up the stairs, advance the good leg first.

When going down the stairs, advance the bad leg first

Conpartment Syndrome

Think 5 Ps

When in doubt, ask yourself...

Is this the safest option

When Studying Pharmocology

Study the classifications of meds (Antihypertensives) and each family in that classification (ACE inhibitors/Beta blockers/Calcium Channel blockers/Diurectics). The classification tells you what the meds action is (antihypertensives- decrease BP). The family generally will all act the same, have similar side effects, nursing considerations (ACE inhibitors – dry cough is an adverse reaction). Understand the action and effects on the body. Pay attention to nursing consideration.

Strategy for answering questions

If your topic includes something you "suspect" is happening -> a data answer that "validates/confirms" (gives you concrete evidence of what you thought was happening) = an appropriate priority answer option. You want to confirm what you suspect before you implement thus that data answer helps you help the client/situation.

Decision Tree

To help you remember, and so you can take with you during your NCLEX exam -
Use Your Hand! Raise it high and wave it--You have the answer!

-First finger - index finger = Step 1 Identify your topic *points you in the right direction.
Read the stem only (question not the answers)
rephrase into 2-3 of your own words
not sure - take a look at your answer options for clues

-2nd Finger - Middle finger = Step 2 Data vs Implementation
*this is usually the most difficulty step to understand--that is why it is the middle finger ;-) *(Do you need more date before you flip the person off or are you going to go ahead and implement it?) Determine if you need more data or validate (confirm) what you are thinking with more data or you need to “do” something about the problem (implementation).
An "action" that gives you data about the client or situation is a “data” answer option (VS, physical assessment findings, asking questions, Lab values/results, etc)
An "action" that does something for your problem/situation and does not give you data = implementation (sitting patient up, turning patient, give O2, give meds, etc)
The NCLEX tests your thinking on "do you know when you need more information (data) or do you know when you have enough information and you need to "do" something for a problem/situation (implementation)
If you have a mix (data and implementations)--then you have the ability to prioritize and eliminate answer options. The NCLEX is testing your thinking!
Start with looking at the assessment answers first and determine if you need more "data" in this situation, if it makes sense for the topic, and if it may confirm "validates" what you were thinking. Then the assessment is appropriate -- hold on to it.

**Validation = "confirms" what you were thinking. An example is you have a client that is diabetic and jittery -- you think (“suspect”) possible "hypoglycemia". A data answer that "validates" what you were thinking would be "getting the blood sugar". The blood sugar gives you concrete evidence -**validation** of what you thought was going on. A data answer that “validates” is an appropriate priority answer option.

-3rd Finger -Ring Finger = Step 3 Maslow - Physical vs Psychosocial
*ring finger signifies marriage - thoughts/feelings, social activities, emotions, love, belonging
Physical answer options are needed to survive = air, water, food, shelter, safety, etc.
Psychosocial answer options are not needed to survive = emotions, thoughts/feelings, love/belonging, social activities, emotional support, teaching for later use, expected pain,etc.
Physical answer options take priority over psychosocial answer options = Eliminate psychosocial answer options if they do not make sense -> think "what will kill them first"
*** Expected pain is considered psychosocial but think better -> if pain is indicative of being severe/sudden and/or a physical problem (loss of life/limb/organ) then consider it physical. Severe pain can cause “shock” which is a threat of loss of life.

4th Finger -pinky-Step 4 ABC's
*pinky = prioritize - Use the ABC's, *pinky promise to prioritize
Airway, Breathing and Circulation answer options take priority over other answer options.
When you have all Physical answer left, use the ABC's to prioritize your answer options.
** Your correct answer will address the topic -> Think Better -- remember that if you have a circulation problem, you need a circulation answer. If you have a breathing problem, you need a breathing answer. Do NOT just go for the breathing answers.

5th Thumb = Step 5 Evaluation
*it is your THUMBS UP--as long as you think about what the outcome is and that it makes sense --you are OKAY
What is the outcome, if I do this what will be the outcome?
Does this make sense for my topic? Does it help me here and now?
Is this safe and effective?
If I can do 1 thing and walk away, will this help me help my client?

***Now, you can't raise that hand unless you have your arm--**remember your arm is your content review
-for your hand to work, you must have your arm--you must review content.
Use the Decision Tree with every question. Questions can either be Evaluation questions and/or Priority questions. With Evaluation questions – use the shortcut Step 1 and Step 5 (know your topic and evaluate whether it is a true/false statement). With Priority questions use all the steps within the Decision Tree to find the priority answer. Steps 2 through 4 help you to prioritize and Eliminate answer options that are not priority to find the best answer option. Also remember to think about priority questions as “If I can do 1 thing and go home”.

You CAN do it –the Decision Tree will help you think better and get you were you need to be. Stay in control of every question and be confident with the strategies you have learned and practiced. Remember –as long as you are getting question = you are still in the game –don’t give up.

Think before you answer...

Is your topic a physical or psychosocial topic? your answer should match

i.e You want to know if your client is in pain.. Topic: pain (psychosocial) Answer: Ask you client to rate the pain (psychosocial)

A wrong answer would be.. Observe your clients urinary cath.. It didnt say your client was unconscious so you would ask first.

RICE

Rest Ice Compression Elevation

(moderate ankle sprain)

Balanced suspension traction

Weights should be hanging freely

DASH Diet

Dietary Approaches to Stop Hypertension

-fruits, veggies, potassium, decreased salt, etc

PEG Tube

Percutaneous Gastrostomy Tube

-sewn in

-you want to compare tube length to the measurement recorded after insertion to verify placement

-want in high fowlers

-warm feeding to room temp

Tubes

Remember, tubes are just an extension of your patient, observe before reporting, unless life threatening

ie Patient with a urinary cath complains of having the need to urinate... You will want to observe for kinks, etc

*Never secure tubing to bed linens or rail but upper abdomen is okay

Isometric

Same length

-So if your patient was preforming isometric exercises you would want the muscle to stay the same length, no stretching, so i.e placing the foot on the ground and pushing down, it is cramping the calf muscle but it is not stretching it

COAL

Cane Opposite Affected Leg

-Remember up with good, down with bad

-Cane should be at the level of the greater trochanter

If a patient has had a long leg fracture...

Shortness of breath is indicator of fat embolism

-24-72 hours post fracture is highest risk

If high respiratory rate with some apnea is a answer, it is not right. Even though apnea may be more severe than shortness of breath, you have to read the whole answer. The high respiratory rate is compensating for the apnea. So, in this case, shortness of breath is more extreme

"Do not explore" Therapeutic Communication.

What does it mean?

It mean exploring the patients delusions or hallucinations

Depression-- aceSS

Lower case-- decreased

-appetite

-concentration

-energy

Upper Case-- Increased

-Social Isolation

-Sleep

Withdrawal Tip

No matter the substance, withdrawal is the opposite of the effect of the substance

i.e Alcohol is a depressant, so therefor, the withdrawal effects will be stimulation.. cant sleep, diarrhea, shaky hands, tremors, etc

Alcohol Withdrawal

CNS stimulation-- excitability-- mild symptoms occur 6-12 hours after last drink

Tip on Cocaine

Stimulant will effect the heart-- tachycardia

Stages of Grief-- SAR

Shock and disbelief

Awareness of the pain (loved one was experiencing)

Restitution/Resolutions

TIP

If the face is red, raise the bed

If the face is pale, raise the tail

(trouble breathing--face will be read-- raise the HOB)

(If in shock--face is pale--trendelenburg--feet up head down)

When positioning.. think..

What are you trying to prevent?

What are you trying to promote?

Urine specific gravity

1.002 and 1.030

The higher the # the less fluid--dehydration-- urine is more concentrated therefor weights more

The lower the # the more fluid--more diluted--fluid overload--weights less

Urine output

Minimum- 30ml/hr (not normal but stable)

Normal: 1500mL/day (about 62.5ml/hr)

Heart Failure

Left--Lungs

Right--Rest of body

Erbs Point

Left sternal border, 3rd intercostal space

--Think.. E backwards is 3 (and it rhymes)= 3rd intercostal space

Valve sounds

All People Eat Taco Meat

Aortic

Pulmonic

Erbs point

Tricuspid

Mitral (bicuspid or apical)

Homonymous Hemianopsia

Can happen with a stroke

-Loss of half of the vision in both eyes and is common with Unilateral Neglect

-patient may turn head side to side when eating

Herbals

If its got a G it'll make 'em bleed

-Ginko, Garlic, Ginseng, etc

St johns wart

Contraindication for blood thinners because it can act like vit K

MRI concerns

Metal in the body (M&Ms) (MRI & Metal)

-Pearcings, Intra-uterine implant, pacemaker, etc

For a Fem-pop bypass..

You never want to remove the dressing just reinforce (you cant see insertion site)

-If you believe the patient may be bleeding internally, check BP

Side Effects vs Adverse Effects

SE- more common, less severe

AE- more intense, more life-threatening

Cephalosporins and Penicillin

Are cousins, share some of the same reaction

Patient that is allergic to one may be allergic to the other

What lab to look at with Warfarin?

INR

What lab to look at with Heprin?

PTT

Think--Ptt--squish the 2 Ts together (tt) and you have an H (heprin)

Ace Inhibitors

Give them Ace they will cough in you face

-Common adverse reaction is dry cough

Stupor

Not responsive

Albuterol

Stimulates lungs--stimulates side effects--tachycardia

Think--did we stimulate TOO MUCH? Is patient stable?

Nitropatch

Should be removed at night to reduce the chance of tolerance build up

NCLEX land

Is a perfect world, you have everything you would ever need

-keep personal experience out!

-You only have 1 patient unless otherwise stated

When answering

Eliminate wrong answer first

-Answer must relate to topic

-If one part of the answer is wrong, The WHOLE thing is wrong

-Is this the safest answer?

-no "What-ifs"

-If question says left or right side, take your hand and place it on that side so that you dont forget

Vertical Chain of command

When supervisor is notified

Strategy for answering Risk factor questions

Who is at high risk?

Go through each answer and make a tally for each risk in that answer and at the end put the number of tallys in order and boom you have your answer

Peripheral vs Central Cyanosis

Understand that "core measure" (inside the body) gives us the best info on client status. Environmental temp can change skin color. note the pattern--ear, hands, and lips are on the periphery/Conjuctivae is encased in the body (core)