Assessments Flashcards

1
Q

What is ISBAR + when it is used

A
  • This is used to give a report/handover
    1. I (Identity)
  • Identify self name, position, location and who you are talking to
  • Identify patient name, age, sex and location
    2. S (Situation)
  • State purpose = The reason I am calling …..
    3. B (Background)
  • Tell the story
  • Current problem
  • Relevant history, exams, results, management
    4. A (assessment)
  • What you think is going on
    5. R (request)
  • State request/what you are wanting
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2
Q

Describe clinical reasoning cycle

A
  1. Consider the patient situation
    - Describe context, people and situation
  2. Collect cues
    - review current information
    - gather new information
    - Recall knowledge
  3. Process information
    - analyse data to get understanding
    - narrow down to only relevant information
  4. Identify problem
    - use facts to make diagnosis
  5. establish goal
    - describe what you want to happen/desired outcome
  6. take action
    - select course of action
  7. Evaluate outcomes
    - evaluate effective of action and outcomes
  8. Reflect on process and new learning
    - think of what you have learn from process
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3
Q

What is SOAPIE + when to use it

A
  1. Subjective
    (what patient told you)
  2. Objective
    (What you see/observe)
  3. Assessment
    (preform an assessment that best suits their needs/what they look like)
  4. Plan
    (Treatment plan for them, any tests they need)
  5. Intervention
    (Document any actions that were taken eg. meds, bloods, oxygen)
  6. Evaluation
    (evaluate test results, increase, add or decrease to best suit)
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4
Q

What is ADPIE + when to use it

A
  • Used to provide care to patient
    1. Assessment
  • interview patient and family
  • observe behaviour
  • preform exams
    2. Diagnosis
  • Develops diagnosis for patients situation
    3. Planning
  • develop plan and use smart goals to achieve this
    4. Implementation
  • implement the care plan and smart goals
    5. Evaluation
  • evaluation how successful the plan was.
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