Evidence Based Assessment
The nurse uses a problem solving approach by using these 6 steps in the nursing process:
What is Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation?
The is always doing this and knows this is the first step of the day!
What is assessing?
The normal respiration rate
The nurse phones the MD for blood pressure medication for patient admitted with HR 100 Respiration 16 BP 160/98. Which finding is important to report:
What is Blood pressure 160/98?
The nurse is collecting data about what the patient says, this type of data is known as:
What is Subjective data?
To determine if the medication is effective the nurse would be doing this:
What is evaluation?
Normal heart beat
What is 60-100?
The nurse uses SBAR in which situation
What Handoff of Care?
ABC's are not just letters in the alphabet but also:
What is airway, breathing, Circulation?
The nurse has 6 patients to care for the day, which process will best ensure each are assessed and cared for:
What is planning?
What is not palpable or absent of nodules?
The nurse reports which abnormal finding: HR 96, RR14, BP 89/82
What is hypotension 89/82?
A systematic approach to practice that emphasizes that all patient be treated with most current and best practice techniques led to what development:
What is Evidence Based Practice?
The nurse is aware of the importance of setting goals and expectations that are realistic and measurable in this step:
What is outcome identification?
Pupil accommodation to distance
Hand gestures would be which type of communication
What is nonverbal communication?
Once you have clustered items that are related, as you gather information and complete an assessment you also think about ____________ to guide your next steps.
What is Prioritization, Level 1,2,3..?
Level 1: ABC
Level 2: Mental change, acute pain
Level 3: lack of knowledge, problems with activity, rest
Collaborate with interdisciplinary team, provide health teaching and promotion and document after every action.
What is implementation?
The nurse is taking serial measurements of pulse and blood pressure when the patient is known to have volume depletion, taking multiple antihypertensive, or report fainting
What is orthostatic vital signs?
The nurse is examining a patient and determines an order needs clarification and uses which systematic approach to report to use
What is I-SBART