Intro to Assessment Flashcards
Types of Assessments:
- Admission
- Focused
- Time-lapse
- Emergency
What are the phases of the interview?
- Preparatory phase
- Introductory phase
- Maintenance phase
- Concluding phase
Preparatory phase:
Before the nurse meets the patient
Introductory phase:
Begins when the nurse and patient meet
Maintenance phase:
Nurse and patient work toward achieving the specific goal
Concluding phase:
The interview is completed
Two types of data:
Subjective, Objective
Describe subjective data:
Patient’s feelings and statements about their health problems
-Symptoms: “I feel”
Describe objective data:
Observable, perceptible, and measurable data.
-Signs: VS, labs, diagnostics, assessments
Ex. Therapeutic communication, Offering self
opening up a convo; I am a good listener
Ex. TC, Open-ended questions:
encourage people to open up and share
Ex. TC, Opening remarks:
“What brought you in?”, “what’s on your mind?”
Ex. TC, Restatement:
clarify client’s message by repeating same statement back to client
Ex. TC, Reflection
assess what the client things about something; get pt to go a little deeper
Ex. TC, Focusing
be direct, acknowledge what they need and focus back on goal
Ex. TC, Encourage elaboration:
“Tell me more!”
Ex. TC, Seek clarification
I want to understand more, ask for an example
Ex. TC, Giving information:
Professional information; client still makes choice
Ex. TC, Look at alternatives:
Promote pt decision making and autonomy
Ex. TC, Summarizing
restate what you think pt is trying to get accross
SBARR Stands for:
I= Introduce yourself S= Situation B= Background A= Assessment R= Recommendation R= Read Back
S= Situation
“What’s going on right now?”
-pt name, unit, room #
B= Background
“What are the circumstances leading to the situation?”
-Admission date/dx, allergies, baseline VA/assessment, code status, meds, labs
A= Assessment
“What is your assessment of the problem?”
-Focused subjective and objective system assessments, impression
R= Recommendation
“What is your recommendation?”
-Order change, referral, provider visit, etc.
R= Read Back
Read back the order, restatement
