General Knowlegde Flashcards
What is the IDENTIFY aspect of the ISBAR framework stand for?
Specify
- Who are you?
- Where are you?
- Patients name, age, gender and department
What is ISBAR used for, and what does it stand for?
Transfer of critical information to other health professionals.
Identify
Situation
Background
Assessment
Recommendation
What is the SITUATION aspect of the ISBAR framework stand for?
What is the problem/ reason for contact?
- Im calling because… (Describe)
- Ive noticed major changes in… (ABCDE)
- I have measured the following values… (RR, SpO2…)
- I have received test results…
What is the BACKGROUND aspect of the ISBAR framework stand for?
If it’s urgent and/or you are concerned- speak up
- Admission, diagnosis and date
- Previous illnesses of significance
- I don’t know what the problem is the pts condition has deteriorated
- Relevant problems and treatment/ interventions to date
- Allergies
What is the ASSESSMENT aspect of the ISBAR framework stand for?
Assessment (of the situation and background)
- I think the problem/reason for the pts condition is related to (respiration, circulation, neurology)
- I don’t know what the problem is but the pt has detorated.
- The pt is unstable and we need to do something.
- I am concerned
What is the RECOMMENDATION aspect of the ISBAR framework stand for?
Request specific advice and interventions, and clarify expectations
- I suggest …/What interventions do you recommend?
Immediate intervention
investigation/ treatment
How often should I… - When should I next make contact? When will you be here?
- Confirm messages and interventions with a closed loop.
What is SOAPIE used for, and what does it stand for?
Format for documentation
- Subjective
- Objective
- Analysis
- Plan
- Implementation
- Evaluation
What does the SUBJECTIVE part of SOAPIE stand for?
What the patient says or information that only the patient can provide personally. This should include
- Perceived pain
- Symptoms (numbness or tingling)
- Medical and family history
- Allergies
What does the OBJECTIVE part of SOAPIE stand for?
Objective data. What the nurse observes, hears, sees, and feels during the patient assessment.
Obs, ECG, CT, etc…
What does the ANALYSIS part of SOAPIE stand for?
After subjective and objective assessment data is collected, the nurse should make an initial analysis of the patient’s condition and identify any appropriate nursing diagnoses.
Pt dehydration due to nausea and vomiting, evidenced by pt having a “dry mouth”, and dark, odorous urine.
What does the PLAN part of SOAPIE stand for?
Once an initial nursing diagnosis has been identified, the nurse must create a plan of action.
This may include repositioning, requesting pain medication from the providers, applying oxygen per protocol, or providing emotional support.
The plan should be patient-centered and based on the nursing diagnoses.
What does the IMPLEMENTATION part of SOAPIE stand for?
After the plan of action has been decided, the actions (interventions) should be put into motion. Sometimes, a nurse’s plan does not go exactly as planned and that is to be expected. It is important to document all of the interventions performed, and even the ones that were attempted.
What does the EVAULAUATION part of SOAPIE stand for?
Finally, the outcomes of the interventions need to be evaluated. The evaluation often includes reassessing the patient.
If the evaluation reveals that an intervention did not work, a different plan may need to be made.
Repeat the last few steps as necessary until a satisfactory outcome is reached.
