Therapeutic Communication Skills - How to Develop and Build Rapport

THERAPEUTIC COMMUNICATION

1. HANNAH B. PICHON RN,MAN

2. Therapeutic communication is face-to-face processof interacting with clients and family member that allows them to express their own thoughts and feelings in order to build trust. is a part of holistic and patient centered care which covers different aspects of physical and psychological needs of patients through conveying information and making an interactive and relaxing relationship with the nursing student /nurse.

3. The three main purposes of therapeutic communication for a nurse are: to provide education to patients, to provide support to patients, and to establish a relationship in which the patient feels free to express any concern and to build trust.

4. COMMUNICATION IN NURSING PROCESS Good communication between nurses and patients is essential for the successful outcome of individualized nursing care of each patient. To achieve this, however, nurses must understand and help their patients, demonstrating courtesy, kindness and sincerity

5. BASIC COMMUNICATION CONCEPTS Effective communication is one of the Standards of Professional Performance established by the American Nurses Association. The standard states, “The registered nurse communicates effectively in all areas of practice.” There are several concepts related to effective communication such as demonstrating appropriate verbal and nonverbal communication, using assertive communication, being aware of personal space, and overcoming common barriers to effective communication.

6. Why is therapeutic communication between nurses and patients important? Nurses use therapeutic communication techniques to facilitate clients' awareness of their thoughts and feelings and mutually develop goals and an individualized plan of care. Nurses provide reflective and nonjudgmental feedback to clients to help them clarify their thoughts, goals, and coping strategies

7. open ended question - are NOT simple “yes” or “no”, they instead require a response that is not simply yes or no which promotes discussion with the patient. Example: How do you feel right now? Can you please tell me more about what was happening to you that led you to be hospitalized here? Tell me what concerns you have right now?

8. Documenting and Reporting Documentation serves as a permanent record of client information and care. Reporting takes place when to or more people share information about client care , either face to face or by telephone. (inform)

9. Purposes of client’s Record/chart communication legal documentation research statistics education audit and quality assurance planning client care reimbursement

10. 5 Basic Components of the Tradiotional Client Record Admission sheet Medical History Physician’s order Sheet Nurses Notes Special Records nd reports( referrals, Xray reports, Laboratory findings, report of surgery, anesthesia record, flow sheets, Vital signs, I & O, Medications.

11. PROGRESS NOTES: Nurses or narrative notes (SOAPIE FORMAT) S - Subjective Data O - Objective Data A - Assessment P - Planning I - Intervention E - Evaluation Flow Sheets(data that are monitored) Discharge notes or Referral summaries

12. KARDEX provides a concise method of organizong and recording data about a client making information readily accesible to all members of the health team. it is a way to ensure continuity of care from one shift to another and from one day to the next. it is a tool for change- of - shift report. But endorsement is not simply reciting content of kardex. the health care needs of the client is still promary basis for endorsement. is for planning and communication purposes only.

13. KARDEX ususally includes the following data: personal data basic needs alleries diagnostic test daily nursing procedures medications, IVF and blood transfusions treatment like oxygen sutioning, mechanical ventalation(settings)

14. Characteristics of Good Recording Brevity (concise/complete) Use of ink/ permanence Accuracy Appropriateness Completeness and chronolgy/ organization/ sequence/timing 6. Use of correct terminology 7. Signed 8. In case of Error 9. Confidentiality 10. Legal awareness 11. Legible

15. Brevity entries are concise. complete sentence is not required Start entry with a capital and end the entry with period even if the entry is a single word phase. 2. Use of Ink/Permanence avoid felt pen or pencil for permanence of data, because the clients chart can be used as an evidence in a legal court.

16. 3. Accuracy Chart objective facts, not your interpretation or opinions. Correct I ncorrect ate 50% of the food served -ate with poor appetite refused medication -uncooperative seen crying -depressed placed complaint of the client in Quatation mark to indicate that it is his statement. ex. patient complained of “chest pain radiating down the left arm.”

17. Objective Data are also to be charted. ex. skin cold clammy diaphoretic with vital signs taken as follows temp.- 35.8 C PR - 110 bpm RR - 30 cpm BP - 150/90 mmHg refusal of medication and treatment must be documented.

18. 4. Appropriateness only information that pertain to the clients health problems and care are recorded. 5. Completeness and chronolgy/ organization/ sequence/timing date / time is entered in the date column on the the first line , p hysicians visits . medicationsand treatment should be chartedimmediately (avoid double charting and double entry) 6. Use standart terminolgy use only those abbreviations and symbols that is approved by the institution.

19. 7. Signed Affix signature, place at the end of the charting at the right hand margin of the nurses notes. signed each entry with your full name and status ex. SN-student nurse RN- registered nurse script not printing is used for the signature 8. In case of ERROR correct errors by drawings a single (horizontal line) through the error.

20. write the word error above the line, then sign your signature no ink eradication, erasures or use of occlusive materials. 9. Confidentiality only the health personnel who participate in the care of the client are allowed to read the chart. 10. Legal awareness chart only what you personally have done, observed, heard, smelled or felt. do not discard any part of the client record. 11. Legible writing must be clear and easily read by the others.

21. REPORTING 1. Change of shift reports or endorsement 2. Telephone Reports (transferring /referring) clear,accurate and concise. when the call was made: date and time who made the call (telephone,cellphone or verbal order) to who, information was given. 3. Telephone orders clear,accurate and concise. when the call was made: date and time who made the call (telephone,cellphone or verbal order) the order should be counter signed within 24 hours