Assessments + Prevention
Comprehensive, Focused, Emergency: A patient comes to the outpatient clinic for a follow-up visit concerned about a urinary tract infection. What type of assessment will the nurse likely provide?
Focused assessment
The RN states "no worries, everything is going to be just fine" after a pt expresses fear of an upcoming surgery.
1. Therapeutic or not?
2. What technique is it an example of?
1. Non therapeutic
2. False reassurance
Pre-interaction, Beginning, Working, or Closing Phase of the interview: The nurse introduces themselves and states the purpose of the interview
Beginning phase
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
Primary, Secondary, or Tertiary prevention: An RN is leading a support group for patients diagnosed with cancer to help with management of chemo side effects.
Tertiary prevention
Patient: "I feel like there is a radio inside my ear."
RN: "Tell me what you mean by saying there is a radio in your ear."
1. Therapeutic or no?
2. What technique is this an example of?
1. Yes
2. Clarification
Give an example of 1 closed-ended and 1 open-ended health history question
Examples-
Closed: "do you have a family history of HTN?"; Open: "Tell me about your pain; walk me through your surgical history"
To document a progress note, there are multiple format options, including narrative, SOAP, _____, and ______.
PIE, DAR (data, action, response)
Primary, Secondary, or Tertiary: Implementing more frequent mammograms for those at risk for breast cancer
Secondary
Patient: "My mother said something really hurtful to me the other day when she visited..."
RN: Nodding, "go on..."
1. Yes
2. Elaboration
In a health history interview,
The primary data source is ______. The secondary data sources can include ____ and _____.
-The patient
-Family members, the medical record/documentation
Name at least 3 situations when hand hygiene should be used
Specific occurrences for optimal effectiveness (per WHO):
-1 prior to contact with the patient
-2. after contact with the patient or environmental equipment
3. After removal of gloves
4. Prior to invasive procedures
Name the 4 techniques in physical assessment and the order in which they normally occur. (Exception: GI assessment)
Inspection, Palpation, Percussion, Auscultation
Pt: "I've been having trouble dropping those last few pounds."
RN: "“I think you should try intermittent fasting, it really worked for my friend."
1. Therapeutic or not?
2. What technique is it an example of?
1. No
2. Giving advice
****DAILY DOUBLE****
What does the acronym "OLDCARTS" stand for,
And why is it used?
-Onset
-Location
-Duration
-Characteristics
-Alleviating/aggravating factors
-Radiation
-Timing
-Severity
-*Used for obtaining the history of present illness
-Safety
-Coordination of care/communication
-Legal document
-Quality assurance
-Financial reimbursement
-Education
-Research
The __________ framework is used in documentation when we organize all of our findings from our head to toe assessment based on each system in the body.
Body Systems
Name at least 4 types of non-verbal communication.
-Touch
-Eye contact
-Facial expressions
-Posture
-Gait
-Gestures
-General physical appearance; dress and grooming
-Sounds
-Silence
Name at least 3 components of a full health history. (ex - "demographic information")
-Reason for seeking care
-HPI
-Past medical/surgical history
-Current medications, allergies
-Family history
-Functional health assessment
-Growth and development
-Review of Systems
-Psychosocial & Lifestyle factors (ex. religious/cultural preferences that may impact care; mental health assessments; violence assessments; sexual history)/
-When should gloves be worn?
-When should gloves be changed?
WHEN DO YOU WEAR GLOVES?
-when touching blood, body fluids, secretions, excretions, or contaminated items.
-when touching mucous membranes or non-intact skin of patients
-When contact with any “wet” body secretion is anticipated.
*purpose- protect selves and patients
WHEN DO YOU CHANGE GLOVES?
-Between procedures/tasks on the same patient after contact with a material that contains high concentration of microorganisms (ex after a dressing change, after trach care)
-when going from a contaminated to cleaner area. Ex. You won’t help your incontinent patient clean up an then use the same gloves when touching an open wound
Remove gloves promptly after use. Perform hand hygiene after removing gloves. Don’t wear gloves inside a room then out in the hallway, or type on computer with them on.