3.1 Nursing Process, Assessment

Question 1

Comprehensive assessment

Answer 1

Head to toe
Patient centered interview
Holistic approach

Question 2

Problem focused assessment

Answer 2

Quick screenings

Follow up assessment (pain/nausea)

Question 3

Holistic manner of gathering data?

Answer 3

Physiologic (IPPA)
Psychosocial
Cultural
Spiritual
Lifestyle factors

Question 4

Subjective assessment data

Answer 4

Subjective

Information given directly to you by the patient or family/caregiver

Question 5

Objective assessment data

Answer 5

Objective
Information that you gather from your physical assessment, clinical observations, lab or diagnostic test results, and the patient’s pertinent history

Question 6

Cues for symptom analysis

Answer 6

Location
Quality
Quantity
Chronology
Setting
Aggravating or alleviating factors
Associated manifestations
Meaning of the symptom to patient

Question 7

60 Second assessment

Answer 7

ABC without touching the patient: what data leads you to believe there is a problem with airway-breathing-circulation? Is the problem urgent or non-urgent? What clinical data indicates that the situation needs immediate action and why? Who needs to be contacted and do you have any suggestions/recommendations?
1. tubes and lines
2. respiratory equipment
3. patient safety
4. environmental survey
5. sensory: what are the senses telling you
6. critical thinking
7.

Question 8

Assessment documentation: painting a picture

Answer 8

Assessment findings need to be in a clear, accurate and timely manner
Use correct terminology
Utilize descriptive words to report what you determine with your senses
Provide facts, do not formulate opinions or judgements
Quotes are the best way to document subjective data
Documentation is a legal and professional responsibility or nursing

Question 9

SBAR

Answer 9

Situation: clearly and briefly define the patient situation
Background: provide clear, relevant background information that relates to the situation
Assessment: statement of your professional conclusion
Recommendation: what do you need from this individual

Question 10

SBAR use and benefits

Answer 10

Forms a communication is used for patient hand off or change of shift report

Allows for an expected and organized way of giving and receiving information

Supports patient safety and continuity of care