Intro to Assessment and Communication

Question 1

ISBARR

Answer 1

Introduce
Situation
Background
Assessment
Recommendations
Repeat

Question 2

Define health assessment

Answer 2

collect and analyze data to make judgments about wellness (may be used by self and others)

may involve individuals/families/communities

Question 3

What are the 4 purposes of nursing health assessment?

Answer 3

• understand person’s experience
• identify strengths that promote health (what independence they can have)
• identify needs and clinical problems
• evaluate the effects of therapeutic plans and interventions

Question 4

5 types of assessments

Answer 4

admission
focus
time lapse
emergency
head to toe (basic nursing)

Question 5

admission assessment

Answer 5

comprehensive, includes other providers, health background

Question 6

focus assessment

Answer 6

responding to a change or apparent situation (e.g., knowing that they had an intervention on their foot)

Question 7

time-lapse assessment

Answer 7

looking at the patient over time

Question 8

emergency assessment

Answer 8

critical – supporting oxygenation and cardiovascular system

could also be a mental health assessment

Question 9

basic nursing assessment

Answer 9

head to toe model (there are a few options, will be finetuned as we specialize)

Question 10

four phases of interviewing

Answer 10

preparatory - before meeting
introductory - nurse and pt meet
maintenance - work towards goal
concluding - interview complete

Question 11

two types of data

Answer 11

subjective (symptoms) and objective (signs)

Question 12

two sources of data

Answer 12

primary: the patient
secondary: all other sources including diagnostic tests

consider how reliable the source is

Question 13

inspection

Answer 13

close and careful visualization of the person as a whole and of each body system

• good lighting
• privacy and comfort
• every encounter
• compare findings to subjective data
• inform pt of need to look at area and why

Question 14

gluteal cleft

Answer 14

butt crack :)

Question 15

critical observation

Answer 15

compare to patient’s baseline and “normals” for each body part

Question 16

light palpation

Answer 16

use of hands/touch to gather data: 1cm or 1/2inch depression

Question 17

deep palpation

Answer 17

use of hands/touch to gather data: 5cm or 2 inches

Question 18

which part of hand do you use to assess skin temp

Answer 18

back (dorsal)

Question 19

which part of hand assesses texture, moisture, tenderness?

Answer 19

fingers

Question 20

when do you palpate known tender areas

Answer 20

last (don’t hurt them first – you’ll get a more accurate exam if they’re in less pain for most of the exam)

Question 21

percussion

Answer 21

tapping of body organs and structures to produce vibration and sound (direct and indirect)

Question 22

auscultation

Answer 22

listening to sounds (usually using stethoscope)

Question 23

four characteristics of sound

Answer 23

pitch - high/low
intensity - soft/loud
quality - gurgling, blowing, musical
duration - short, long, when

Question 24

should the stethoscope be used on the skin or over clothes

Answer 24

on the skin (preferred, later on you may be able to use over clothes)

Question 25

goal of therapeutic communication

Answer 25

rapport and trust

Question 26

offering self

Answer 26

active listening – part of therapeutic communication

Question 27

opening remarks

Answer 27

esp. in primary care or community, asking why the pt is seeking care

Question 28

restatement vs. reflection

Answer 28

restatement: repeating back what pt said
reflection: asking the pt about feelings, importance, changes based on tone or what they’ve said (I’m hearing a lot of questions about visiting hours….)

Question 29

I of ISBARR

Answer 29

Introduce yourself

Question 30

S of ISBARR

Answer 30

Situation: what is going on right now? (Why are you communicating)
Including pt’s name, unit, room #

Question 31

B of ISBARR

Answer 31

Background: What are the circumstances leading to the situation
Admission date/dx, allergies, baseline VS/assessment, code status, meds, labs, test results…

Question 32

A of ISBARR

Answer 32

Assessment: what is your assessment of the problem? Focused subjective and objective system assessments

Question 33

Rs of ISBARR

Answer 33

Recommendation (order change, referral, provider visit)
Read back (restatement)