Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing Assessment > Intro to Assessment and Communication > Flashcards

Intro to Assessment and Communication Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Pharmacology flashcards NCLEX-RN® flashcards Nursing Mental Health flashcards Nursing Fundamentals flashcards Nursing Safety & Infection flashcards Nursing Adult Health flashcards NCLEX-PN® flashcards Nursing Management of Care flashcards Nursing Pediatrics flashcards Nursing Maternity flashcards
1
Q

ISBARR

A 
Introduce
Situation
Background
Assessment
Recommendations
Repeat
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Define health assessment

A

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

may involve individuals/families/communities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the 4 purposes of nursing health assessment?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

5 types of assessments

A 
admission
focus
time lapse
emergency
head to toe (basic nursing)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

admission assessment

A

comprehensive, includes other providers, health background

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

focus assessment

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

time-lapse assessment

A

looking at the patient over time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

emergency assessment

A

critical – supporting oxygenation and cardiovascular system

could also be a mental health assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

basic nursing assessment

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

four phases of interviewing

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

two types of data

A

subjective (symptoms) and objective (signs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

two sources of data

A

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

consider how reliable the source is

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

inspection

A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

gluteal cleft

A

butt crack :)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

critical observation

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

light palpation

A

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

17
Q

deep palpation

A

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

18
Q

which part of hand do you use to assess skin temp

A

back (dorsal)

19
Q

which part of hand assesses texture, moisture, tenderness?

A

fingers

20
Q

when do you palpate known tender areas

A

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

21
Q

percussion

A

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

22
Q

auscultation

A

listening to sounds (usually using stethoscope)

23
Q

four characteristics of sound

A

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

24
Q

should the stethoscope be used on the skin or over clothes

A

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

25
Q

goal of therapeutic communication

A

rapport and trust

26
Q

offering self

A

active listening – part of therapeutic communication

27
Q

opening remarks

A

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

28
Q

restatement vs. reflection

A

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….)

29
Q

I of ISBARR

A

Introduce yourself

30
Q

S of ISBARR

A

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

31
Q

B of ISBARR

A

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

32
Q

A of ISBARR

A

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

33
Q

Rs of ISBARR

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

Nursing Assessment (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions