Hospitalized Adult Health Assessment Practice Flashcards

Flashcards covering shift report protocols, clinical judgment models, and specialized assessments for the hospitalized adult patient.

SBAR (Shift Report)

A communication framework used during shift reports consisting of Situation, Background, Assessment, and Recommendation.

Shift Assessment

The process of gathering information to compare and contrast to the shift report just received.

Clinical Judgment Model Steps

The sequence of actions including: Gather information, Determine any abnormals that are present, Interpret the findings, Take action, and Evaluate whether actions were effective.

Nursing Process

A clinical framework consisting of five steps: Assess, Diagnose, Plan, Implement, and Evaluate.

Skin Assessment (Hospitalized Patient)

Focused evaluation including IV therapy, pressure injuries, wounds, and infected incisions.

Respiratory Assessment (Hospitalized Patient)

Assessment focused on oxygen administration (nasal cannula or mask), tracheostomy, and chest tubes.

Abdominal/GI Assessment (Hospitalized Patient)

Assessment including gastrostomy tubes, nasogastric tubes, wound drains, ostomies, and urinary catheters.

Musculoskeletal Assessment (Hospitalized Patient)

Assessment focused on casts, external fixators, and assistive devices.

Neurological Assessment (Hospitalized Patient)

Assessment including respiratory assessment, pupillary response, and skin integrity.

Hypoxia Interventions

Raise the head of the bed (HOB), administer $O_2$, and give bronchodilators or appropriate medications as ordered.

Infection Interventions (R/T incision)

Monitor the wound, change dressings as ordered, use hand hygiene, and give ordered antibiotics.

Skin Integrity Interventions (Pressure Injury)

Monitor the site for change, change position every $2$ hours, apply a protective dressing as ordered, and maintain adequate nutrition.