Week 4 Assessment Flashcards
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
ability to understand and share the feelings of another person. It involves putting oneself in someone else’s shoes,
Empathy
A __________ is a professional and purposeful connection between a (counselor, therapist, nurse, or mentor) and an individual seeking assistance or support
helping relationship
_________, 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
__________ refers to the exchange of information, thoughts, feelings, and meaning between individuals
Interpersonal communication
_____ communication refers to the internal dialogue and self-talk that occurs within an individual’s mind.
Intrapersonal
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
study of meaning in language.
How words, phrases, and sentences convey meaning,
Semantics
What does SOAP / SOAPIE(R) Charting
Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision
SOAP/SOAPIER
how does the client feel
Subjective
SOAP/SOAPIER
Results of physical exam, vital signs
Objective
SOAP/SOAPIER
What is the client’s status
Assessment
SOAP/SOAPIER
Is a changed needed in the treatment
Plan
SOAP/SOAPIER
What occurred, what did the nurse do?
Intervention
SOAP/SOAPIER
What is the client’s outcome after the intervention
Evaluación
SOAP/SOAPIER
What changes are needed to the care plan?
Revision
SOAP/SOAPIER
Paitent is hypotensive
Assessment
SOAP/SOAPIER
Patient instructed not to get out of bed, notify provider
Plan
SOAP/SOAPIER
0.9 NS 500 cc bolus IV x 1 given per order
Intervention
SOAP/SOAPIER
After intervention:
BP = 110 / 62, patient denies dizziness and light headedness
Evaluation
_____ 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
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
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
