1. Domain: 4 Communication- (9% 17 Questions)
Domain 4 is about communication. Seventeen of the 185 questions are related to this domain.
Domain: 4 Communication- (9% 17 Questions)
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2. Objectives
Identify the topics in Domain 4 and their corresponding elements.
Apply elements and topics to the chapters and modules in the study guide.
Identify additional resources available.
Assess your current knowledge.
Develop a study plan.
Identify your assignments.
The objectives of this presentation are:
Identify the topics in Domain 4 and their corresponding elements.
Apply elements and topics to the chapters and modules in the study guide.
Identify additional resources available.
Assess your current knowledge.
Develop a study plan.
Identify your assignments.
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3. Chapter (Domain) 4: Communication
Module 1: Verbal and Nonverbal Communication
Topics:
Collaborative reporting to interdisciplinary health care providers
Communication techniques
Interviewing techniques
Universal Protocol
Chapter four in the study guide corresponds to domain four in the CNOR exam content outline. Questions on the exam will cover the topics listed above related to domain 4.
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4. Chapter (Domain) 4-Communication
Elements (your nursing interventions):
Identify barriers to communication and incorporate effective solutions.
Communicate patient status and changes to the interdisciplinary health care providers (critical laboratory values, medical condition, medications, allergies, implants/implantable devices)
Use best practices for effective communication, including hand offs and read back for verbal orders
Some of the reading assignments for Domain 4 are duplicates from Domains 1 and 2. As you read, keep in mind key terms of Domain 4. These terms include communication, documentation, and hand offs. One important key to your patient plan of care is your ability to communicate. Barriers to effective communication can include patients who are deaf or blind and patients who are unable to communicate effectively related to anxiety or ability to understand. Identifying barriers will give the nurse the ability to create effective solutions.
Patient safety is directly affected by the communication among health care providers. Continuity of patient care through communication is key to patient safety. Hand off communication from the preoperative nurse to the intraoperative nurse should include at a minimum, all concerns related to procedure, medical condition, abnormal laboratory values, and allergies. Using the topics and elements of Domain 4, identify areas within your practice setting that you participate in for safe patient care and communication. The Joint Commission has a list of National Patient Safety Goals (NPSG) that include the requirement to read back verbal orders and critical laboratory values for verification. Review the Joint Commission website and the NPSG’s.
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5. Communicate patient status and changes to the interdisciplinary healthcare providers
One principle underlying effective communication in the operating room is that:
staff should only speak up if asked.
the surgeon should control the flow of information.
the perioperative nurse is at the center of all communication.
all members of the team should be encouraged and feel free to communicate with other team members.
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6. Answer
D. all members of the team should be encouraged and feel free to communicate with other team members.
SRP (2014), Transfer of Patient Care Information. I.a., p. 501.
A multidisciplinary team's planning and coordination of processes ensures that the needs and perspectives of the patient and all caregivers are included, which can decrease risk and promote the safe transfer of information. An environment that promotes open communication will support safe patient care.
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7. Chapter (Domain) 4: Communication
Module 2: Written Communication
Topics:
Interdisciplinary plan of care
Medication reconciliation
Proper use of documentation tools
Regulatory guidelines
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8. Chapter (Domain) 4-Communication
Elements (your nursing interventions):
Maintain patient confidentiality
Provide information to the patient/family according to HIPAA guidelines (status, updates)
Regulations and ethical issues prevent us from sharing confidential information. The Health Insurance Portability and Accountability Act (HIPAA) regulation is the pinnacle of maintaining patient confidentiality. Your facility will have a policy related to HIPAA regulations. Most facilities require some form of annual education about the legality of maintaining confidentiality. Many facilities now have a personal identification number (PIN) that patients can give out authorizing release of information that the patient agrees to. Again, The Joint Commission website has a lot of information related to guidelines and regulations related to HIPAA and confidentiality.
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9. Sample Element Review
Module 1: Verbal and Nonverbal Communication Topic: 1. Collaborative reporting to interdisciplinary health care providers Element: Communicate patient status and changes to interdisciplinary healthcare providers “Standardization of transfer of patient information processes improves the accuracy, reliability, and quality of information.” SRP (2014), Transfer of Patient Care Information, p. 501
Module 1 discusses verbal and nonverbal communication. One of the topics under this heading is collaborative reporting to interdisciplinary healthcare providers. Your nursing actions might include communicating the patient status and changes to interdisciplinary healthcare providers. Your hand-off communication might be in the format of Situation, Background, Assessment, and Recommendation (SBAR), written, or verbal. The important point is that the communication contain important patient information and be in a standard format. Patient safety has been shown to improve when a standardized format is used for hand-off communication. All pertinent information should be included in the report to the next care giver or level of care provider. The Perioperative Standard and Recommended Practices has information under the title “Transfer of Patient Care Information” that contains recommendations for hand offs.
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10. Study Plan
Apply the topics and elements of Domain 4 to your case study patient. Can you come up with sample questions that may be asked as applicable to each of the elements? Quiz your study group on questions you create that apply to Domain 4.
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11. Domain 5: Transfer of Care- (5% 9 Questions)
Domain 5 is all about the transfer of patient care. Nine of the 185 questions are related to this domain.
Domain 5: Transfer of Care- (5% 9 Questions)
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12. Objectives
Identify the topics in Domain 5 and their corresponding elements.
Apply elements and topics to the chapters and modules in the study guide.
Identify additional resources available.
Assess your current knowledge.
Develop a study plan.
Identify your assignments
The objectives of this presentation are:
Identify the topics in Domain 4 and their corresponding elements.
Apply elements and topics to the chapters and modules in the study guide.
Identify additional resources available.
Assess your current knowledge.
Develop a study plan.
Identify your assignments
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13. Chapter (Domain) 5: Transfer of Care
Module 1: Transfer of Care Between Members
Topics:
Coordination of interdisciplinary care services
Documentation of the transfer of care
Transfer of care criteria
Elements (your nursing interventions):
Collaborate with interdisciplinary services
Document transfer of care
Collaboration with health care team members within and outside the perioperative area is essential for a holistic approach to patient care. Patient status will determine the interdisciplinary services required to ensure the patient care process is completed on discharge. Case workers are helpful in assisting with post discharge care including appointments, transportation, and any requirements for home health care needs. Communication among all members of the interdisciplinary team is key to providing complete and safe patient care.
A patient that will be transferred from the PACU to another level of care, or discharged home must meet facility defined post anesthesia discharge criteria. The patient must meet appropriate criteria on assessment to be discharged home. The patient is required to have a ride home and it is recommended he or she have a support person present for the first 24 hours because the effects of anesthesia may linger. All assessment data, education, and discharge instructions must be documented in the patient chart.
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14. Chapter (Domain) 5: Transfer of Care
Module 2: Discharge Planning for Patients Leaving the Facility
Topics:
Patient postoperative follow-up communication following regulatory guidelines
Perioperative patient education techniques
Postoperative complications
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15. Chapter (Domain) 5: Transfer of Care
Elements (your nursing interventions):
Evaluate patient status to facilitate transfer to the next level of care.
Document perioperative education.
Provide and document post discharge follow-up communication according to regulatory guidelines.
Surgical procedures are completed in a variety of settings based on patient status and planned procedure. The post procedure patient assessment will determine where the patient is transferred for the next phase of care. The different levels may include PACU or ICU, and eventually an inpatient unit, a rehabilitation facility, or home. There are certain standards of practice related to the specific patient populations and health status of patients in the postoperative phase. The hand off to an inpatient unit should include the patient status and any complications that may have occurred in the intraoperative phase of care.
Same day surgery patients that will be discharged will required discharge instructions, an essential part of patient education. Instructions should be reviewed with the patient and a responsible adult. Depending on the patient’s level of postoperative awareness and the amnesic effects of any sedation used, the patient may or may not be able to verbalize the instruction or demonstrate specific understanding of instructions. All postoperative instructions and patient or responsible adult responses need to be documented. Written discharge instruction should also be given to the patient to take with them.
Each facility has policies and procedures related to their documentation requirements. The adage of “if it wasn’t charted, it wasn’t done” is still true. Some requirements include that documentation needs to be factual, legible, use of appropriate abbreviations, be dated and signed, and any errors need to have a single line through it with a correction. These requirements are true for an electronic health record (EHR) and for paper charting.
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16. Postoperative Complications
One potential source for injury while positioning a patient are shearing forces. Shearing forces result when:
two surfaces rub against each other.
tissue is exposed to excess moisture during surgery.
heat and moisture combine with excessive pressure.
the folding of underlying tissue when the skeletal structure moves and the skin remains stationary.
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17. Answer
D. the folding of underlying tissue when the skeletal structure moves and the skin remains stationary.
Alex (2014), Chapter 6: Positioning the Patient for Surgery, Figure 6-1, p. 157. 
Parallel forces create shear. Examples include the patient being placed in trendelenburg position and sliding on the operative bed. Friction results from two surfaces rubbing together. Heat and moisture are not key to shearing injuries.
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18. Perioperative Patient Education Techniques
To ensure that the patient and/or responsible adult have an understanding of their discharge medications, the perioperative nurse should encourage the patient and family members to:
sign for the medications.
watch a videotape regarding medications.
verbalize the receipt of medications.
repeat or teach back important considerations.
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19. Answer D. repeat or teach back important considerations.
Alex (2014), Chapter 10: Postoperative Patient Care and Pain Management, p. 283. 
“Review with the patient before discharge the interventions used and their efficacy, and provide specific discharge instructions regarding pain and its management. Have patient “teach back” or repeat instructions in his or her own words.”
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20. Evaluate patient status to facilitate transfer to the next level of care
The patient in the PACU during Phase III is:
preparing for self-care or care in an extended care facility.
preparing for discharge.
considered immediate postoperative.
ready for phase IV then home.
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21. Answer B. preparing for discharge.
B&K (2013), Chapter 30: Postoperative patient care: Postanesthesia care. (p. 602).
There are three phases of post anesthesia care. The level of care required for each level decreases as the level increases. A patient in phase three has returned to a safe physiological level and is ready to be discharged.
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22. Sample Element in Review
Module 2: Discharge Planning for the Patient Leaving the Facility
Topic: 4. Perioperative patient education techniques
Element: Document perioperative education
Alex
Chapter 2: Patient Safety and Risk Management: Ambulatory Surgery Considerations
Education for patients and their family members is usually completed by the preoperative and postoperative nurses. Intraoperative nurses have brief moments of time to educate their patients on what to expect in the operating room.
“Patient and family education and preparation for discharge are critical to the well-being of surgery patients. Each of the chapters in this book that reviews a surgical specialty has a discussion of this critical aspect of perioperative nursing care in order to assist both the nurse and the patient in discussing and anticipating what will be needed during the postoperative recovery and convalescence period.” (Alex 2014, p. 20)
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23. Study Plan Apply the topics in Domain 5 to one of your patients
Who did you collaborate with in the preoperative preparation area? Anesthesia professional? Preoperative nurse?
Did you do any patient teaching before patient transfer from the preoperative area to the operating room?
Spend a day with the nurses in PACU or wherever phase II recovery is provided and observe their process for determining patient readiness for transfer to the next level of care.
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24. Assignments Study Guide
Read chapter 4.
Complete activities in chapter 4.
Read chapter 5.
Completed activities in chapter 5.
We will apply chapter 4 and 5 to a case study in the next presentation.
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