Week 4 Assessment Flashcards by Jade Ring

CUS communication tool

Concerned:

Clearly state your concern. Express your worry or unease about a specific aspect of the patient’s condition or care.

Uncomfortable:

Clearly communicate that you feel uncomfortable with the current situation. This emphasizes the emotional aspect of your concern and the impact it may have on the patient.

Safety:
Explicitly reference the safety implications. Connect your concern and discomfort to

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ability to understand and share the feelings of another person. It involves putting oneself in someone else’s shoes,

Empathy

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A __________ is a professional and purposeful connection between a (counselor, therapist, nurse, or mentor) and an individual seeking assistance or support

helping relationship

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_________, also known as lateral violence or workplace bullying, refers to aggressive, intimidating, or disruptive behavior that occurs among individuals at the same hierarchical level within an organization.

Horizontal violence

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__________ refers to the exchange of information, thoughts, feelings, and meaning between individuals

Interpersonal communication

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_____ communication refers to the internal dialogue and self-talk that occurs within an individual’s mind.

Intrapersonal

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The SBAR communication tool helps ensure that essential information is effectively communicated, reducing the risk of miscommunication and improving patient safety.

It is widely used during shift handoffs, when escalating concerns to a higher level of care, or when collaborating among healthcare team members.

What does SBAR stand for?

Suitation
Background
Assessment
Recommendation

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study of meaning in language.

How words, phrases, and sentences convey meaning,

Semantics

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What does SOAP / SOAPIE(R) Charting

Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision

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SOAP/SOAPIER

how does the client feel

Subjective

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SOAP/SOAPIER

Results of physical exam, vital signs

Objective

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SOAP/SOAPIER

What is the client’s status

Assessment

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SOAP/SOAPIER

Is a changed needed in the treatment

Plan

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SOAP/SOAPIER

What occurred, what did the nurse do?

Intervention

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SOAP/SOAPIER

What is the client’s outcome after the intervention

Evaluación

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SOAP/SOAPIER

What changes are needed to the care plan?

Revision

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SOAP/SOAPIER

Paitent is hypotensive

Assessment

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SOAP/SOAPIER

Patient instructed not to get out of bed, notify provider

Plan

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SOAP/SOAPIER

0.9 NS 500 cc bolus IV x 1 given per order

Intervention

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SOAP/SOAPIER

After intervention:

BP = 110 / 62, patient denies dizziness and light headedness

Evaluation

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_____ assessment is an on going process integrated with nursing care. Uses to determine the status of a particular problem identified in an earlier assessment

Exp.

Hourly I&O

Problem focused assessment

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This type of assessment is preformed during a crisis to ID life threatening problems

Exp.

Rapid Assessment of patients airway, breathing status, and circulation during cardiac arrest.

Emergency assessment

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Examples

Reassessment of a patient’s health status outpatient or home care or a shift assessment in the hospital

Time-lapsed assessment

____ involves including patients, families, and healthcare professionals in shared decision making

Patient-centered care

Represents a person's own internal sense of gender (formed by age 3)

Gender identity

____ is how someone presents gender within context of culture and society

Gender expression

3 phases of an interview

Introduction, Discussion, Summary

At the end of an interview summarize data with patient allowing them to clarify information Everyone is on the same page True or False

True

8 parts of comprehensive health history (Betty Chased Her Pet Puppy, Finding Pink Rabbits)

Biographical data Cheif Complaint History of Present Illness Present Health Status Past Health History Family History Personal and Psychosocial History Review of systems

When recording the Cheif Complaint use medical terminology in the report True or False

False Use patients own words

What are the (9) parts of History of Present Illness

Previous history Onset Location Duration Characteristics Aggravating/ Alleviating factors Related Symptoms Treatment Severity

Current health conditions Medications Allergies Are all part of which part of the Comprehensive Data

Present Health Status

Personal Status Family/ Social relationships Diet Functional ability Mental Health Drug use Health Promotion activities Environment/ recent travel

Personal / Psychosocial History

Childhood illnesses Surgies Hospitalizations Accidents / injuries

Past Health History

DM CAD Stroke Cancer Mental Illness HTN Alzheimer Kidney Endocrine Seizures High cholesterol Are conditions to ask about during this part of a Complete History

Family History

Screen for these 2 violence related problems during the interview

Domestic violence Human trafficking

Do these things Noticing verbal and nonverbal Cues Not making assumptions Listening to full answer

Active listening

Do these things Exp. Go on. Uh huh, then? Nodding shift forward in seat

Facilitation

Do these things Exp. I feel so on edge. What do you mean by on edge?

Clarification

Do these things Uses to gain clarification by restating phrase patient used in the form of a question

Reflection

Do these things When noticing inconsistencies Try not to sound accusatory Tone matters

Confrontation

Shares the conclusions drawn from data given You shared you only sleep 4 hours a week and work 60. I am wondering if this is why your so fatigued

Interpretation

Do these things Condenses data into clear and concise order. Helpful when patient is all over the place

Summarization

Which is better Why did you wait so long to come to the hospital I am wondering what made you decide to come to the hospital when you did

2nd

Is it ever appropriate to share personal stories with patients

Yes Be breif

Are silences good during an interview

Yes, they can be used to get more information

Assessment Overview Collect data ( Nursing history interview, physical exam) Ongoing Assessment (Interview , examination) ______, ________, ______

Validate, organize, record data

In male adults above 50 years of age (_) , does administering pain relief medication throughout the surgery (_) compared to taking the same medicine post-surgery (_) reduce pain relatively (_) six hours after the surgery (_)

P I C O T

In adult cancer patients experiencing fatigue (_), what is the effect of meditation (_), compared with standard care (_), on quality of life (_) within 6 months (_)

P I C O T

Does telemonitoring blood pressure (_) in patients with hypertension (_) affect blood pressure control (_) within one year of initiation of the medication (_)

I P O T

Step of Evidence Based Practice (EBP) to assess and ask when researching to formulate a searchable Clinical Question by helping to develop key terms.

Patient Intervention Comparison Outcome Time.

Current health condition, Medications, Allergies Make up what?

Present Health Status

Is tone of voice verbal or nonverbal communication

Nonverbal

Readiness for enhanced communication

Wellness diagnosis

Impaired verbal communication R/T insufficient stimuli, cultural incorgruence, physiological condition, alternation in perception, emotional disturbance AEB difficulty speaking, slurred speech, inappropriate verbaliztion, disoriented to person, place or time, inability to speak language of caregiver

Nursing Diagnosis

Assessment Documentation is written how?

Subjective Objective Assessment Plan Intervention Evaluation Revision

Privacy Age Culture Gender expression & Identity Language Physical/ Emotional Distress Sensory / Cognitive Are all concerned with

Paitent-Centered Approach