Exam 2 Study Guide

What Therapeutic Communication Is

Communication is a complex interactive process of sending and receiving messages, influenced by illness, culture and age. Therapeutic communication narrows that: the interaction focuses on the patient and the patient's concerns, it is caring and empathetic, and it is a skill — it takes practice. The slide's last line is the one students skip: the nurse should be comfortable with her self-concept and aware of her own biases, values, culture and communication style. You cannot manage your effect on a patient without that.

Nonverbal communication — as important as the words

The deck lists nine channels: physical appearance, facial expressions, sounds (gasps), silence, posture and positioning, gait, gestures, eye contact, and touch.

Eight factors influencing communication

The slide's own eight: developmental level · gender · sociocultural differences · roles and responsibilities · space / personal territory · physical, mental and emotional state · values · environment.

Building the skill

Therapeutic vs Nontherapeutic Techniques

The ten therapeutic techniques are boxed at the front of this guide, because the deck's notes name them as tested content. Their counterparts matter just as much — most application questions are built by putting a nontherapeutic response in the answer options and seeing whether you pick it.

From the ATI Communication modules — techniques the deck does not name

The blueprint tells you to complete the ATI Communication assignments, so ATI’s own list is fair game. It overlaps the deck’s ten but is not identical. Where the two ever disagree, the deck wins — these are additions, not replacements.

Nontherapeutic behaviours ATI names that the deck does not: closed-ended questions (inhibit spontaneity, discourage the client from continuing) · automatic responses — clichés that minimize the client’s importance · arguing or disagreeing, which insinuates the client is misinformed or lying · defensive responses, where the nurse takes the opposite side rather than hearing criticism · judgmental responses, which create dependency on the nurse’s value system · minimizing the client’s feelings · changing the subject, which discredits the client’s feelings and usually signals the nurse’s discomfort · and focusing on yourself rather than the client.

Assertive vs aggressive

Assertiveness is the professional standard — on an exam, the assertive option is nearly always correct. Note that assertiveness includes standing up for others, not only for yourself, and that accepting help is on the assertive side rather than a weakness.

The deck contrasts two. ATI names four types, and the two extra ones are where most real workplace conflict actually lives.

Professional Behavior, Culture, and Special Situations

Professional boundaries

• Non-professional involvement — a little social chatting can build rapport, but watch the drift. The deck's two examples: discussing your own family member with the same illness, and discussing how much you need a day off. Both move the focus from patient to nurse.
• Sexual boundary violation; visiting patients beyond the role of nurse.
• Do not confuse privileged intimacy with friendship. This is the line the deck draws explicitly — the nurse–patient relationship grants access no friendship does, and that access is not friendship.

Intercultural communication

The blueprint names “language barrier strategies and laws related to interpreter use” by name. The deck states the rule; ATI supplies the specifics below. Nothing here contradicts the slide — it fills it in.

Other points: use tools such as picture boards and common-phrase lists; be aware of gender roles in a culture and of societal biases around gender and sexual orientation; notice that routine questions often assume a heterosexual patient.

The phases of the therapeutic relationship — three or four, depending who is asking

From Taylor Ch 8. Not on the slides, and the two sources you have been pointed at do not agree on the count — see the box below the table. Included because it is the structure the whole chapter is organised around, and it survives into every later course.

Length and depth vary enormously — a few minutes in acute care, or weeks across a long admission. The phases overlap in practice rather than running cleanly one after another.

Open-ended, closed-ended and focused questions

The Week 3 prep worksheet asks you to write three open-ended and three closed-ended questions and say when each is used, so this is assigned work as well as textbook content. Taylor adds a third type.

The data you collect, and where it came from

Two classifications run underneath every assessment in this course, and they are independent of each other — students collapse them into one, which is exactly what an exam item is built to catch.

Adapting technique to special situations

Hearing impairment · visual impairment · semi-consciousness · cognitive impairment · mental health illness · crying · anger · alcohol or drug use · the patient asking the nurse personal questions · sexual aggression (inappropriate jokes, flirtation).

The Teach-Back Method

Teach-back should occur with every interaction — it is not a one-time event, and it is practised in chunks, checking each time new information is presented.

Focus on need-to-know and need-to-do. The patient wants to know: What is my main problem? What do I need to do? Why is it important to me to do this? Teach-back is documented in the EHR patient education screen, with teach-back selected as the teaching method.

Health literacy — from the ATI Client Education module

ATI defines literacy as the “ability to read, understand and interpret information written at an 8th grade level or higher.” The clues to low literacy are behavioural, not stated: anxiety and avoidance — the patient who keeps deferring the handout, or who says they will read it later. Strategies: simplified written materials · one step at a time · methods that appeal to several senses · teach-back and repetition, inside a trusting, nonjudgmental relationship.

ATI names exactly two evaluation strategies for patient teaching: questioning (asking for information, which it notes does not threaten the client) and return demonstration for psychomotor skills. It places teach-back inside return demonstration, as the version that adds the cognitive domain — you demonstrate a skill back, or you explain understanding back.

The Medical Record

The record is multipurpose. Six purposes:

1. Legal document
2. Communication and planning care
3. Quality assurance — chart audits
4. Financial reimbursement
5. Education — unique case studies
6. Research

The deck notes students most often underestimate legal document and financial reimbursement — which is exactly why they make good exam questions.

Four terms the prep worksheet asks you to define

The Joint Commission "Do Not Use" list

From Taylor Ch 20. Not on the slides, but the clinical objectives name documentation with approved abbreviations, and this is the short memorizable list — the minimum every organisation must prohibit. It applies to handwritten orders and medication documentation, including free-text computer entry.

What goes in, and when

Flow sheets and progress notes are where most day-to-day nursing documentation happens.

Principles and Formats of Documentation

The five principles

The formats

Reporting Care and ISBARR

A 2009 TJC safety goal required agencies to develop a standardized approach for handoff communications. Written and verbal handoffs are complementary, not alternatives — verbal is best supplemented with written.

Strategies for effective handoff

Organized, complete, accurate, concise, respectful · standard format (ISBAR) · face-to-face verbal update with interactive questioning · limit interruptions · use read-back policies · cross-monitor the handoffs of others. The two highest-yield habits per the deck: read-back and limiting interruptions.

Bedside shift report — the evidence-based standard

• What it is: handoff conducted at the bedside with the patient and family present and participating; outgoing and oncoming nurses verify information together, in view of the patient.
• Why: endorsed by AHRQ — the Agency for Healthcare Research and Quality, the federal agency that studies how care is delivered and publishes evidence-based bedside tools — and supported by TJC handoff safety goals. Associated with fewer handoff errors, falls and preventable adverse events, and better patient engagement, satisfaction and nurse accountability.
• In practice: introduce the oncoming nurse; invite patient and family in; use a standard format such as ISBAR; do a visual safety check; move sensitive details outside the room when privacy requires it.

What a complete change-of-shift report contains

Identifying information, diagnosis, physicians and consultants · current appraisal of health status · changes in condition · allergies, labs, radiology data, head-to-toe assessment, pain management · current orders and medications · activity level and dietary status · abnormal occurrences · family/patient input and discharge plan.

Incident Reports, Family Reporting, and Incivility

Incident / occurrence reports

• Anything out of the ordinary that can potentially cause harm to a patient, employee or family.
• Purpose is quality improvement and risk identification — not punishment.
• Do not ignore mistakes. The provider must be told, for example, if an incorrect medication dose was given.
• The agency keeps the report as factual reference in the event of litigation.
• Complete only the facts of the occurrence — no opinions.

Reporting to family and significant others

Follow HIPAA. Nurses keep families updated, and confidentiality is protected by using a code. Be careful about what is yours to share: a new diagnosis such as a malignancy is the provider's to deliver — the nurse provides support and explains what it means for care.

Incivility and bullying

Organizations address it with: accountability for all staff · education on professional, respectful behavior · zero-tolerance policies and whistleblower protection · leadership training · accessible reporting systems · documentation of bullying behavior.

Integumentary Terminology

The lab lists terminology as a topic in its own right, alongside wound documentation, drainage types, staging and edema. These are the words you are expected to use rather than describe — most of them appear again in context later, but this is the one place they sit together.

Skin, Hair, Nails and Glands

Hair — an appendage of skin: protects against invasion, insulates, aids sensory stimulation and gender identification. Changes with disease: alopecia; dry brittle hair raises a question about nutritional status. Nails — epidermal appendage, nail bed highly vascular; changes with disease — the deck's example is clubbing in chronic hypoxia.

Older Adults, Turgor and Culture

Older adults: thinner skin · more prone to bruising (ecchymosis) and shearing injury · decreased turgor.

Cultural considerations: consider beliefs and practices; a patient may refuse to remove head dress or refuse skin-to-skin contact (wear gloves); ask about cultural practices. Cupping and coining are common in Southeast Asia — rubbing a coin across the skin in a specific manner to treat health concerns. The marks can be mistaken for abuse. More than half of all patients are likely to self-treat a skin lesion with what is culturally familiar before seeking professional help.

Subjective and Objective Skin Data

Subjective — risk factors

• Family history — irregular moles, melanoma (strong familial risk)
• Past medical history — irregular moles, severe sunburn as a child, skin cancers, PVD, diabetes, HIV. Diabetes and PVD mean decreased blood flow → impaired wound healing, and neuropathy means decreased sensation. Sensory loss = cannot sense the need to change position = risk for pressure injury. HIV/AIDS and chemo/radiation = weakened immune system
• Allergies — medications, insects, nuts, bees, and the reaction
• Medications — photosensitivity, allergies, chemo/radiation, OTC, supplements. Corticosteroids risk thinning of the skin and edema
• Lifestyle / occupational / behavioral — nutrition, activity, wheelchair-bound, weight
• Focus is on risk of melanoma and pressure-related skin breakdown; teach self skin assessment

Symptoms to ask about: pruritus (where, how long, remedies tried); rash (add recent allergen exposure — new meds, yard work, unusual foods — and recent illness, fever, chills, headache, which could indicate an infectious skin disorder); single lesion or wound (acute or chronic? medical, surgical or traumatic? any factors delaying healing — diabetes, impaired circulation, immune suppression, obesity, smoking).

Skin Lesions — Macules, Papules, Plaques and Pustules

Wound Healing — Principles and Intention

Principles

• Intact skin is the first line of defense against microorganisms.
• Use surgical asepsis in caring for a wound; sterile technique with open wounds.
• The body responds systemically to trauma.
• Adequate perfusion is essential for a normal body response to injury.
• Normal healing is promoted when the wound is clean and free of foreign material.
• The extent of damage and the person's state of health affect healing.
• Response to a wound is more effective if proper nutrition is maintained.

Phases of Wound Healing, and What Goes Wrong

From Taylor Ch 33. The deck gives the three intentions but not the four phases, and names no wound complications. Both are standard chapter content.

Classifying a wound

That last row is the same distinction the staging system uses: Stage 2 is partial thickness; Stages 3 and 4 are full thickness.

Nutrition and Wound Healing

Nutrition runs through this deck at six separate points — it is a factor affecting the skin, a factor affecting healing, a pressure-injury risk factor, a Braden subscale, a lab value, and a prevention intervention. Collected here because it is easy to meet six times and learn zero times.

Pressure Injury — Definition, Mechanism, Risk

Because of CMS (Centers for Medicare and Medicaid Services), practice changed: an occurrence report is filed for any pressure injury present on admission, plus staff in-services, policy and procedural changes, documentation guidelines. Many facilities require nurses to photograph pressure injuries on admission and place the photo in the chart.

Problem naming: Risk for pressure injury = potential · Pressure injury = actual.

The Braden Scale and UPMC SKIN

Notice SKIN is the Braden subscales minus friction/shear and activity — same concepts, fewer letters. If you remember one, you can reconstruct the other.

Staging Pressure Injuries

Classifying, Documenting and Preventing

Labs and diagnostics

Scraping · culture and sensitivity (C&S) · biopsy · nutrition labs: albumin, prealbumin, total protein.

Problems / hypotheses

Prevention — nursing actions

• Maintain clean, dry, wrinkle-free linens
• Perform a daily pressure injury risk assessment
• Clean and dry skin following incontinence; apply moisture barrier creams
• Use tepid water, pat skin dry
• Reposition in bed at least every 2 hours, in a chair every 1 hour
• Lift — don't pull — the patient up in bed
• Maintain heels off the bed surface (float the heels)
• Ambulate as soon as possible and frequently; assist with ROM while in bed
• Prohibit massage over bony prominences
• Provide adequate hydration (2–3 L/day) and meet protein and caloric needs

Wound vac (negative pressure): promotes healing of open wounds — they heal inside-out.

What Pain Is

Threshold is physiological and remarkably similar across people; tolerance is personal and varies enormously. Mixing the two up is the classic error.

The Joint Commission standard (2016–present): "The hospital assesses and manages the patient's pain." Nurses must assess and reassess pain regularly; organizations set their own policy for which patients and how often — commonly every 4–6 hours. TJC's 2022 clarification: it does not require treatment until pain scores reach zero, and does not push opioid prescribing.

Under-treatment has physical and psychological consequences — anxiety, fear, depression. Challenges include looking for nonverbal signs where there is cognitive impairment or a communication barrier such as language or mechanical ventilation.

Neuroanatomy, Nociception and the Gate

Glutamate is the neurotransmitter responsible for communication between the peripheral and central nervous systems. Pain travels via the lateral spinothalamic tracts → thalamus → limbic system (where the emotions controlling pain are produced) → cerebral cortex, where the sensation is recognised as pain.

Categories of Pain

Pain is categorized two ways: by duration (acute or chronic) and by origin (nociceptive or neuropathic).

Neuronal windup — repeated assaults on the neurons produce an enhanced response.

Dimensions of pain, and what shapes the experience

Dimensions: physical · sensory · behavioral · sociocultural · cognitive · affective · spiritual.

Factors affecting the experience: age · fatigue · culture · ethnic variables · family, genetic sensitivity, gender · religious beliefs · environment and support people · anxiety, fear and other stressors · past pain experience.

Assessing Pain and the Assessment Tools

On the Q of OPQRST the deck adds a warning: let the patient describe the pain — if you supply the words, they may say what they think you want to hear. The same caution appears in the tips list as "do not put words in the client's mouth."

Two behavioural scales the deck does not list, worth recognising by name so they do not throw you: PAINAD (Pain Assessment in Advanced Dementia) for patients who can no longer self-report, and CRIES for neonates. Beyond the deck — the deck’s own answer for a nonverbal or cognitively impaired patient is FLACC, and for young children FACES. Answer with those unless a stem names one of these directly.

Patients unable to report pain — the sequence

1. Attempt a self-report anyway
2. Identify potential causes for pain
3. Observe patient behaviors
4. Ask family or caregivers about changes in behavior
5. Attempt an analgesic trial

Lifespan

Older adults: pain is NOT a normal consequence of aging · may be stoic and conceal pain · at risk for under-treatment · ask about effects on diet, sleep and mood · consider comorbidities such as arthritis · assess current medications and how they are taken. Newborns, infants and children: challenging, and also at risk for under-treatment — use FLACC, or FACES for ages 2–7.

Pharmacologic and Non-Pharmacologic Management

Non-pharmacologic measures (Taylor Ch 29)

Distraction · humor · music · imagery · relaxation · cutaneous stimulation · acupuncture and acupressure · hypnosis · biofeedback · therapeutic touch · position.

Cutaneous stimulation, massage and warm compresses are the gate control theory in practice — they stimulate large-diameter fibers to close the gate.

Other routes

PCA · end-tidal CO₂ monitoring · epidural analgesia · local anesthesia · nerve ablation (intractable cancer pain) · nerve blocks (acute surgical pain).

Barriers — patient misconceptions

• "If I ask for something for my pain, I may become addicted"
• "Sometimes it's better to put up with the pain than deal with the side effects"
• "I should somehow be able to control my pain. It is immature to talk about pain"
• "Better to wait until the pain gets really bad — if I take medication for moderate pain it won't relieve severe pain later"
• "I don't want to bother anyone — I know how busy they are"
• "It's natural to have pain after surgery"

Terminology

Muscle tone terms: atony (lack of normal tone/strength) · hypotonicity (decreased tone) · spasticity / hypertonicity (stiff, awkward movements) · spasm (sudden violent involuntary contraction) · fasciculation (involuntary twitching) · tremors (involuntary contraction).

Bones, Joints, Muscles and Connective Tissue

206 bones. They provide the framework of the body, protect vital organs, and are the primary storage and regulation site for calcium and phosphate. Bone marrow is the primary site of red blood cell production. Classified as short (carpal), flat (sternum, ribs), irregular (vertebrae), long (femur). Two types: compact (shaft and outer layer) and cancellous (spongy — ends and center).

Skeletal muscle movement is stimulated by the CNS and is voluntary; smooth and cardiac muscle are involuntary. The musculoskeletal system depends on the neurologic system — which is why musculoskeletal findings always require a paired neurologic assessment.

Terms of movement

Flexion / extension / hyperextension · dorsiflexion / plantar flexion · abduction / adduction · rotation (internal, external) · pronation / supination · inversion / eversion · circumduction · protraction / retraction · elevation / depression · opposition (thumb to little finger).

Subjective and Objective Data

Subjective

Pain in joints or muscles; stiffness, swelling, weakness, twitching · neurologic disorders · recent falls, trauma, functional status · past surgeries on muscles, bones or joints · physical problems limiting activity · sports and activities · arthritis, gout · smoking and alcohol · family history of bone cancer, rheumatoid arthritis, osteoporosis, scoliosis.

Postmenopausal women: ask about maximum height (compare with current — gradual height loss occurs with age), calcium supplements, and bone density.

Objective — inspection

Symmetry (compare sides for deformity, swelling, lesions, lacerations, muscle size) · height compared with past · posture and alignment, sitting and standing · spine curvatures · gait, balance and coordination · active range of motion · muscle strength.

Palpation and range of motion

Assess joints for warmth, inflammation, edema, stiffness, crepitus, deformity, tenderness and limitations. Ask for active ROM first; assess passive ROM only if active is limited and clinically appropriate.

Specific joints: temporomandibular — three fingers on the jaw, open and close, protract and retract the mandible; a click suggests improper alignment. Neck — palpate for crepitus, note rotation. Wrists and hands — carpal tunnel is assessed with the Phalen test and Tinel test.

Muscle Strength and Neurovascular Status

Neurovascular check — the 5 P's plus

Assess pain, pallor, pulses, paresthesia, paralysis, plus temperature, capillary refill, movement and sensation — all distal to the area of concern.

Report: new or worsening pain · deformity, swelling, redness, warmth or suspected fracture · new weakness or inability to bear weight · numbness, tingling, loss of sensation, inability to move fingers or toes · cool, pale, cyanotic or mottled extremity · absent or diminished pulses compared with the opposite side · delayed capillary refill · unsafe gait.

Normal reference values used in the guide's sample documentation: pulses 2+ bilaterally, capillary refill less than 3 seconds, strength 5/5 in all extremities.

The Morse Fall Scale

Lifespan, Labs, Problems and Interventions

Cultural and gender considerations: males have larger, stronger bones; females are at higher risk of osteoporosis — specifically Caucasian women. Osteoporosis has no cure; the goal is prevention. Working conditions matter — heavy lifting and repetitive motion cause musculoskeletal injury.