Communicating Nursing Process

Ninuk DK

Communication

is a process in which people affect one another

through exchange of information, ideas, and feelings.

MODES OF COMMUNICATION
Verbal communication. Uses spoken or written words.
Nonverbal communication. Uses gestures, facial
expression, posture/gait, body movements, physical
appearance (also body language), eye contact, tone
of voice.
Electronic communication. computer messages, i.e. e-mail.

Communication consists of a sender,

a message, a receiver, and feedback.

Nursing Process
Specific to the nursing profession
A framework for critical thinking
Its purpose is to:
Diagnose and treat human responses to actual
or potential health problems

5 Steps in the Nursing Process

COMMUNICATION

Communicating Nursing Process

Assessment
Plan
Implementation
Evaluation

Nurse
Doctor
Patient
Health care
professionals

Written:
paperelectronic
Spoken

Who

When

How

What
NCP
Patient
Family

Ns-Pt communication
Assessment

Planning/imple
mentation

Evaluation

Gather data
Data validation
Patient preference
Pt participation: modes, level

Evaluate

Ns-Pt Communication strategies

Therapeutic
Building rapport
Style of communication

Ns-Health care team communication

Good communication encourages
collaboration, fosters teamwork, and
prevents errors
Good communication=patient safety

Ns-Health care
communication

Modes

Orally

Written

Content

Electronic

SBAR

Why SBAR
Prevent communication breakdown
Effective; thus improves pt safety

Why does communication

break down?
Different communication styles
High level of activity
Frequent interruptions
No standardization in organizing essential information
Loss of information

What Can Go Wrong?

CONCERN was communicated BUT:
PROBLEM:

was not clearly stated

PROPOSED ACTION: didnt happen

DECISION: was not reached

Physician-RN Communication
Differences in:

Training and practice

Style of communication
Past experience
Level of empowerment
Tone of voice and level of respect

Physician-RN Communication Styles

Nurses are narrative and descriptive
Physicians are guided to be problem solvers- just
the facts please
Other complicating factors

Gender, cultural differences

Prior relationships, hierarchy
Perceptions of teamwork depends on point
of view

Figure 36-8

An example of narrative notes.

Implementation of SBAR will:

Meet Joint Commissions requirements for appropriate
communication for patient hand-offs

Admissions
Transfers
Shift to shift report
Daily rounds

Improve clinician communication in critical and non-critical patient

care situations

Implementing SBAR for patient handoffs

Handoffs include verbal communication
Face-to-face interaction
Opportunity to ask and answer questions
Documentation

Hand-off Communication:
The transfer of care from one provider to another provider
A mechanism for transferring information, responsibility, and
authority from one set of caregivers to another

Shift change
Dietitian to nurse
Unit-to-unit report
Nurse to physician
Physician to
nurse/respiratory
therapy
Nurse to dietitian

Social worker to nurse

Nurse to clinical support
staff/technicians
Respiratory therapy to nurse
Nurse to pharmacy
Physician to nurse/
respiratory therapy

What Is SBAR?
SBAR stands for:
Situation
Background
Assessment
Recommendation/response

Situation:
Whats going on with the patient right now?
Identify yourself
Identify the patient
State the problems concisely

Background:
What is the background on this patient?
How did we get to this point?
Review the documentation
Anticipate questions
State the relevant medical issues

BACKGROUND
Brief synopsis of patient:

State the admission diagnosis and date of admission

State the pertinent medical history
A Brief Synopsis of the treatment to date

Assessment:
What do I think the issues are?

Provide your observations and evaluations of the

patients current state and discuss pertinent
issues/concerns

Patients most recent data (eg, weight changes,

supplement requirement, neurological status,
oral intake)
Include any changes from prior assessment

Assessment
Pertinent objective & subjective information
Most recent vitals
Mental status
Respiratory rate and quality
B/P, pulse rate & quality
Pain
Neuro changes
Skin color
Rhythm changes

Recommendation/Response:
How do we collaborate to form a plan of
action?
Discuss the plan of care to meet the
patients immediate needs
Listen for/seek feedback to ensure that
responder understands the issues

RECOMMENDATION
State what you would like to see done:
Transfer the patient?
Change treatment?
Come to see the patient at this time?
Talk to the family and patient about.?
Ask for a consulting physician to see the patient?

RECOMMENDATION
Other suggestions
CXR
CBC

ABG
Other?

EKG

If a change in treatment is ordered, ask:

How often?
Ask: If the patient does not improve, when
would you want to be called again?

Outcomes
Positive outcomes of effective
communication:
More effective interventions
Improved patient safety
Enhanced employee morale
Improved patient and family satisfaction

A patient who is post-surgical ankle repair is having

unsuccessful pain control. The RN needs to get an order for
improved pain coverage.
S: Hello, this is N from Med/Surg at RSUA. Im caring for Mr. J in room 3.
Im calling regarding his pain control.
B: Mr. J is a 22-year old who had surgical repair of a fractured ankle 2
days ago. He has had very minimal pain control since his surgery. He has
an order for Tylenol 650 mg q 4 hours for minimal to moderate pain and
Morphine IV, 1-4 mg q 2 hours for severe pain. He does not have any
allergies to medications. This is his first time having any type of surgery or
significant injury.
A: Mr. J ranks his pain as a 9/10, with a quality of being sharp and
radiating to his mid-calf area. He is reluctant to ambulate out of bed, even
refusing to get into a chair at the bedside. His pedal pulses are equal, the
surgical site is WNL, and all of his vital signs are stable.
R: I think that Mr. J would benefit from some longer-lasting pain
medications. What would you prefer to order? Are there any exams or labs
you would like to order? What should I call you for in the future regarding
his pain control?

Communication Videos
Hand over
Phone calls
Team round
Poor handover

NCP of Client with Respiratory

Diseases

Five-steps nursing process

Assessment

Evaluate

Implement

Diagnose

Plan

Assessment
History
Anamnesis
Physical examination

History

Physical problems
Function problems
Life style
Smoking
Family Hx
Occupation hx
Allergens / environment
Recreational exposure
Anxiety
S&S

PE
INSPECTION:
Normal A/P: 1:2
Barrel: A/P: 2:2
Funnel: depression lower
portion
Pigeon: Sternum protrudes
outward
Scoliosis: lateral curvature of
thoracic spine

Kyphosis: Hunchback
Lordosis: sway back
Chest rise
Retraction

INSPECTION:
Breathing pattern:
tachypnea, bradypnea,
hyperpnea,
hyperventilation,
hypoventilation, Kussmaul,
Apneustic (gasping), Apnea,
Cheyne-stokes

SS

Dyspnea
Cough
Sputum production
Chest pain
Clubbed fingers
Hemoptysis
Cyanosis

PE
Percussion:
Sonor
Hyper-sonor
Flatness/dull

Auscultation:
Vesicular
Bronchial
Bronchovesicular
Crackles
Wheezes
Pleural friction rub
Stridor/crowing-lrg obst

Early & late signs of hypoxia

Anxiety
Bradycardia
Cyanosis
Depressed respirations
Diaphoresis
Disorientation
Dyspnea

Restlessness
Headache
Agitation
Poor judgment
Retraction
Tachycardia
Tachypnea

Nursing Diagnosis: Definition

The NANDA-I definition of a nursing diagnosis was
adapted from a national, Delphi study by Dr.
Joyce Shoemaker (1984)
Nursing diagnosis is a clinical judgment about individual,
family, or community responses to actual or potential
health problems/life processes. Nursing diagnoses provide
the basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable (NANDA,
1997).

Diagnostic Process
Assessment
Cluster cues / defining characteristics
Generate list of potential diagnoses
Collect additional data to narrow list of potential diagnoses
Determine diagnosis/diagnoses to be treated
Implement plan of care based on identified diagnoses
Evaluate success of plan of care

Formulating a Nursing Diagnosis

Composed of 3 parts:
Problem statement- the clients response
to a problem
Etiology- whats causing/contributing to
the clients problem
Defining Characteristics- whats the
evidence of the problem

Types of Nursing Diagnoses

Actual
Imbalanced nutrition; less than body
requirements RT chronic diarrhea, nausea, and
pain AEB height 55 weight 105 lbs.
Risk
Risk for falls RT altered gait and generalized
weakness
Wellness
Family coping: potential for growth RT
unexpected birth of twins.

Nursing diagnosis
Risk for ineffective respiratory function
Dysfunctional ventilatory weaning
response
Risk for dysfunctional ventilatory
weaning response
Ineffective airway clearance
Ineffective breathing patterns
Impaired gas exchange
Inability to sustain spontaneous
ventilation

Collaborative Problems
Require both nursing interventions and medical
interventions
EXAMPLE: Client admitted with medical dx of
pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy

Planning
Third step of the Nursing Process
This is when the nurse organizes a nursing care
plan based on the nursing diagnoses.
Nurse and client formulate goals to help the
client with their problems
Expected outcomes are identified
Interventions (nursing orders) are selected to
aid the client reach these goals.

Planning Begin by prioritizing

client problems
Prioritize list of clients
nursing diagnoses
using Maslow
Rank as high,
intermediate or low
Client specific
Priorities can change

Goals are patient-centered and

SMART
Specific
Measurable
Attainable
Relevant
Time Bound

Pt will maintain RR 12-20 x/mnt

Pt will state pain level is acceptable 6 (0-10)

Planning-select interventions
Interventions are selected and written.
The nurse uses clinical judgment and
professional knowledge to select
appropriate interventions that will aid the
client in reaching their goal.
Interventions should be examined for
feasibility and acceptability to the client
Interventions should be written clearly and
specifically.

Nursing intervention
Interventions must be directed toward
altering the etiological factors associated with
the dx
When the etiological factor cannot be
changed, the interventions must be directed
toward threatening the signs and symptoms
For risk, interventions must be aimed at
altering/eliminating the risk factors

Nursing intervention

Expected outcome
Research base
Feasibility
Acceptability to the client
Capability of the nurse

Interventions 3 types
Independent ( Nurse initiated )- any action
the nurse can initiate without direct
supervision
Dependent ( Physician initiated )-nursing
actions requiring MD orders
Collaborative- nursing actions performed
jointly with other health care team
members

Implemention
The fourth step in the Nursing Process
This is the Doing step
Carrying out nursing interventions (orders)
selected during the planning step
This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating
physicians orders and monitoring cost
effectiveness of interventions
Utilize NIC as standard

NURSING DIAGNOSIS: Impaired

respiratory function
*

ineffective breathing pattern related to:

increased rate and decreased depth of respirations associated with fear and anxiety
decreased lung compliance (distensibility) associated with pleural effusion and
accumulation of fluid in the pulmonary interstitium and alveoli
diminished lung/chest wall expansion associated with weakness, decreased mobility,
and pressure on the diaphragm as a result of peritoneal fluid accumulation (if present)
respiratory depressant and/or stimulant effects of hypoxia, hypercapnia, and
diminished cerebral blood flow;
ineffective airway clearance related to:
increased airway resistance associated with edema of the bronchial mucosa and
pressure on the airways resulting from engorgement of the pulmonary vessels
stasis of secretions associated with decreased mobility and poor cough effort;
impaired gas exchange related to:
impaired diffusion of gases associated with accumulation of fluid in the pulmonary
interstitium and alveoli
decreased pulmonary tissue perfusion associated with decreased cardiac output.

Desired Outcome

The client will experience adequate respiratory function as evidenced

by:
1.
2.
3.
4.
5.
6.
7.

normal rate, rhythm, and depth of respirations

decreased dyspnea
usual or improved breath sounds
symmetrical chest excursion
usual mental status
oximetry results within normal range
blood gases within normal range.

Interventions

Implement measures to improve respiratory status:

perform actions to improve cardiac output to improve pulmonary tissue perfusion and reduce fluid accumulation in
the lungs
perform actions to reduce fear and anxietyinstruct client to breathe slowly if hyperventilating
place client in a semi- to high Fowler's position unless contraindicated; position overbed table so client can lean
forward on it if desired
instruct client to change position and deep breathe or use incentive spirometer every 1-2 hours
perform actions to increase strength and activity tolerance (see Diagnosis 6, action b) in order to increase client's
willingness and ability to move, cough, deep breathe, and use incentive spirometer
perform actions to promote removal of pulmonary secretions:
instruct and assist client to cough or "huff" every 1-2 hours
humidify inspired air as ordered to keep secretions thin
maintain oxygen therapy as ordered
assist with positive airway pressure techniques (e.g. IPPB, continuous positive airway pressure [CPAP], bilevel positive
airway pressure [BiPAP], expiratory positive airway pressure [EPAP]) if ordered
instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages,
and large meals in order to prevent gastric distention and an increase in pressure on the diaphragm
discourage smoking (the irritants in smoke increase mucus production, impair ciliary function, and can cause damage
to the bronchial and alveolar walls; the carbon monoxide decreases oxygen availability)
maintain activity restrictions; increase activity gradually as allowed and tolerated
administer central nervous system depressants judiciously; hold medication and consult physician if respiratory rate is
less than 12/minute
administer the following medications if ordered:
Diuretics, theophylline, morphine sulfate to decrease pulmonary vascular congestion
assist with thoracentesis and/or paracentesis if performed to allow increased lung expansion.

Intervention

Consult appropriate health care provider (e.g. physician, respiratory therapist) if

signs and symptoms of impaired respiratory function persist or worsen
Monitor for:

rapid, shallow, slow, or irregular respirations

dyspnea, orthopnea
use of accessory muscles when breathing
adventitious breath sounds (e.g. crackles [rales], wheezes)
diminished or absent breath sounds
dry, hacking cough or cough productive of frothy or blood-tinged sputum
limited chest excursion
restlessness, irritability
confusion, somnolence
central cyanosis (a late sign)
significant decrease in oximetry results
abnormal blood gases
abnormal chest x-ray results.

Evaluation- To determine
effectiveness of NCP
Final step of the Nursing Process but
also done concurrently throughout client care
A comparison of client behavior and/or response
to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help client reach
stated goals.

Evaluation
Outcome criteria met? Problem resolved!
Outcome criteria not fully met? Continue plan
of care- ongoing.
Outcome criteria unobtainable- review each
previous step of NCP and determine if
modification of the NCP is needed.
Were the nsg interventions
appropriate/effective?

Evaluation
Factors that impede goal attainment:

Incomplete database
Unrealistic client outcomes
Nonspecific nsg interventions
Inadequate time for clients to achieve
outcomes.

Chronic Obstructive Pulmonary Disease

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COPD:
Chronic Bronchitis vs. Emphysema

COPD- Collaborative Care

Smoking cessation
Medications- bronchodilators (inhaled & step-wise),
Spriva (LA anticholinergic), ICS
Oxygen therapy
RT- PLB, diphragmatic, cough, CPT, nebulization therapy
Nutrition- Avoid over/underweight, rest 30 before
eating, 6 small meals, avoid foods that need a great
deal of chewing, avoid exercise 1 hr before meal, take
fluids between meals to avoid stomach distension

COPD

Nursing Diagnoses

Ineffective Breathing Pattern

Impaired Gas Exchange
Ineffective Airway Clearance
Imbalanced Nutrition: Less than
Body Requirements

Medical Management:
1. Risk reduction- smoking cessation.
2. Bronchodilators.
3. Corticosteroids.
4. Influenza and pneumococcal vaccination.
5. Oxygen therapy.
6. Chest physiotherapy.

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Nursing Management:
1. Improving airway clearance
a. Encourage smoking cessation.
b. Keep patients room as dust free as possible.
c. Administer bronchodilators as prescribed.
d. Use postural drainage position.
e. Encourage coughing.
f. Encourage oral fluids intake.
2. Improving breathing pattern
a. Encourage breathing, coughing exercises.
b. Use pursed- lip breathing at intervals and during periods
of dyspnea.
3. Administer antibiotics as prescribed.

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4. Improving gas exchange

a. Check ABGs.
b. Administer oxygen.
c. Inspiratory muscle training.
5. Improving nutrition.
a. Encourage frequent small meals if pt. is dyspneic.
b. Avoid foods producing gas and abdominal discomfort.
c. Monitor body weight.
6. Increasing activity tolerance.
a. Encourage pt. to carry out regular exercise program.
b. Encourage use of portable oxygen system for
ambulation for patients with hypoxemia.

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Asthma
Chronic inflammatory disorder associated with
airway hyperresponsiveness leading to recurrent
episodes (attacks)
Often reversible airflow limitation
Prevalence increasing in many countries,
especially in children

Asthma-assessment
Cough
Chest tightness
Wheeze
Dyspnea
Expiration prolonged -1:3 or 1:4, due to bronchospasm,
edema, and mucus
Feeling of suffocation- upright or slightly bent forward using
accessory muscles
Behaviors of hypoxemia- restlessness, anxiety, HR & BP, PP
Lung function

PFTs- usually WNL between a acks; FVC, FEV1

PEFR- correlates with FEV
Measurement of airway responsiveness

Asthma
Collaborative Management

Suppress inflammation
Reverse inflammation
Treat bronchoconstriction
Stop exposure to risk factors that sensitized
the airway

Asthma
Collaborative Care
GINA- decrease asthma morbidity/mortality & improve
the management of asthma worldwide
Education is cornerstone
Mild Intermittent/Persistent: avoid triggers,
premedicate before exercise, SA or LA Beta agonists,
ICS, leukotriene blockers
Acute episode: Oxygen to keep O2Sat>90%, ABGs, MDI
B-agonist; if severe- anticholinergic nebulized w/B
agonist, systemic corticosteroids

Asthma

Nursing Diagnoses

Ineffective Airway Clearance

Impaired Gas Exchange
Anxiety
Deficient Knowledge

Pneumonia

Figure 9-8. Alveolar consolidation clinical scenario.

Pneumonia

Nursing Assessment
Fever in any hospitalized patient
Pain
Tachypnea
Use of accessory muscles
Rapid, bounding pulse
Relative bradycardia
Coughing
Purulent sputum

Pneumonia
Signs/Symptoms:
1. Sudden onset; shaking chill; rapidly fever
of 38.3 40 C .
2. Cough productive of purulent sputum.
3. Pleuritic chest pain aggravated by
respiration/coughing.
4. Dyspnea, tachypnea.
5. Rapid, pounding pulse.

Pneumonia

Nursing Assessment
Consolidation
Auscultation
Bronchial breathing
Bronchovesicular rhonchi
Crackles

Fremetis
Egophony
Whispered pectroloquy

Pneumonia

Nursing Diagnoses
Ineffective airway clearance RT copious
tracheobronchial secretions
Activity intolerance RT altered respiratory
function
Risk for fluid volume deficit RT fever and
dyspnea
Knowledge deficit about the treatment regimen
and preventive health measures

Pneumonia

Potential Problems

Hypotension and shock

Respiratory failure
Atelectasis
Pleural effusion
Delerium
Superinfection

Pneumonia

Nursing Goals
Improving airway patency
Conserving energy rest
Maintaining proper fluid balance
Patient understanding of treatment and
prevention
Prevention of complications

Pneumonia

Nursing Interventions
Improving airway patency
Removing secretions coughing vs. suctioning
Adequate hydration loosens secretions
Air humidification to loosen secretions and improve
ventilation
Chest physiotherapy loosens and mobilizes
secretions

Pneumonia
Nursing Interventions
Promoting rest and conserving energy
Bedrest with frequent changes of position
Energy conservation
Sedatives to decrease work of breathing and energy
expenditure unless contraindicated

Promoting fluid intake

Dehydration is possible RT insensible fluid losses through
respiratory tract
If not contraindicated, increase fluid intake to 2 liters/day

Pneumonia

Nursing Interventions

Patient education and home care considerations

Increase activities as tolerated fatigue and weakness
may be prolonged
Breathing exercises to clear the lungs should be taught
Smoking cessation if indicated smoking destroys
tracheobronchial ciliary action, which is the first line of
defense for the lungs. Smoking also irritates the mucus
cells of the bronchi and inhibits the function of alvolar
macrophages
Patient is encouraged to get influenza vaccine because
influenza increases risk for secondary bacterial infections
Staphylococcus
H. influenzae
S. pneumonae

Encouraged to get Pneumovax against S. pneumonae

Nursing Management:
1. Administer medications as prescribed (antibiotics,
antipyretics)
2. Improving gas exchange.
a. Observe for cyanosis, dyspnea, hypoxia, and
confusion.
b. Checking ABGs.
c. Administer oxygen.
d. Place patient in an upright position.

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3. Improving airway patency.

a. Encourage pt. to cough.
b. Suctioning.
c. Encourage increased fluid intake.
d. Humidify air or oxygen therapy.
e. Chest physiotherapy.
f. Changing pt. position frequently.
4. Relieving pleuritic pain.
a. Place patient in semi Fowler position.
b. Administer analgesics as prescribed.
(avoid opioids in patient's with a history of COPD)
c. Avoid suppressing a productive cough.
5. Monitoring for complications.
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6. Patient education.
a. Advise smoking cessation, and excessive alcohol
intake, and heavy exercises.
b. Advise the patient to keep up natural resistance with
good nutrition, adequate rest.
c. Encourage breathing exercises.

Gerontologic Considerations:
Sedatives, opioids, and cough suppressants should be used cautiously
in elderly pt.s, because their tendency to suppress cough and gag
reflexes and respiratory drive. Also , provide frequent oral care for
Pneumonia prevention.

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Respiratory Failure

92

Nursing Management:
1. Administer prescribed medications, such as antibiotics, cardiac
medications, bronchodilators,mucolytics, corticosteroids and
diuretics as ordered.
2. Administer oxygen to maintain Pao2 of 60 mmHg or Sao2 90%.
3. Monitor fluid balance by intake and output measurement, daily
weight.
4. Perform chest physiotherapy and suctioning to remove mucus. Teach
slow, pursed lip breathing to reduce airway obstruction.
5. If the patient becomes increasingly lethargic, can not cough or
expectorate secretions, can not cooperate with therapy, or if PH falls
below 7.30, despite use of the above therapy, report and prepare to
assist with intubation and initiation of mechanical ventilation.
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Pulmonary Embolism
Refers to the obstruction of one or more pulmonary
arteries by a thrombus originating usually in the deep
veins of the legs or the right side of the heart.

Predisposing Factors:
1. Stasis, prolonged immobilization.
2. Previous heart (CHF, MI) or ling diseases.
3. Coagulation disorders.
4. Advancing age, estrogen therapy.

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Signs/Symptoms (occur suddenly):

1. Dyspnea, pleuritic pain, tachypnea.
2. Chest pain.
3. Cyanosis.

Emergency Management:
1. Anticoagulation therapy is used to prevent new clot
formation but does not dissolve previously formed clots.
2. Thrombolytic therapy is used to dissolve clots.

95

Nursing Management:
1. Administer prescribed medications. Anticoagulant (IV
Heparin, followed by Warfarin) and Thrombolytic
(streptokinase). Sedatives (Morphine) to relief pain.
2. Administer oxygen to relief hypoxemia, respiratory
distress, and cyanosis.
3. Apply antiembolism stockings to help improve venous
return.
4. Instruct the pt. do not do activities that increase
venous stasis such as crossing legs, sitting or standing
for long periods. Instruct pt. to elevate the legs above
the level of heart.
5. Patient education.
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Pulmonary edema
Acute pulmonary edema refers to excess fluid in the
lung, either in the interstitial spaces or in the alveoli.
Most often occurs as result of cardiac disorders (Left
CHF, MIetc)

Signs/Symptoms:
1. Crackles.
2. Dyspnea and cough.
3. Tachycardia.
4. Cyanosis, cold diaphoretic skin.
5. Restlessness.
6. Jugular venous distention. (JVD)
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Nursing Management:
1. Administer medications as prescribed. Morphine,
diuretics, cardiac glycosides,vasodilators,aminophylline.
2. Give oxygen in high concentration.
3. Position the pt. upright to decrease venous return and
allow maximum lung expansion.
4. Monitor vital signs and electrolytes balance.

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