Nursing Assessment, ISBARR Reporting, and Basic Principles of Care

Comprehensive practice flashcards covering clinical assessment methods, diagnostic reasoning, ISBARR reporting and EHR documentation, and the eight fundamental principles of nursing practice.

What is clinical reasoning, and what three basic professional skills are essential to performing it effectively according to Bakker (2023)?

Clinical reasoning is a profession-oriented, rapid form of associative and critical thinking linking observations to biomedical knowledge. The three essential professional skills required are observing, analysing, and communicating.

How does a nursing assessment fundamentally differ from a medical assessment?

A nursing assessment gives equal weight to subjective data (the patient's personal experience) and objective data (measurable signs, tests, and physical observations). It focuses on human responses to levels of wellness, life processes, and illness/injury rather than solely on pathology and disease processes.

What are the four main types of nursing history-taking described by Wilkinson (2020)?

1. Initial assessment (first assessment to understand care needs and problems)
2. Heterogeneous history-taking (interview conducted with someone close to the patient when the patient has cognitive difficulties or cannot provide details)
3. Follow-up history-taking (gathering additional data as new information arises)
4. Specific history-taking (targeted data collection conducted during acute situations when rapid action is required)

What distinguishes objective data from subjective data in a nursing assessment?

Objective data are measurable, observable facts verified through physical exams, vital signs, lab tests, and scales (e.g., pulse rate of $100\,\text{beats/minute}$, urine output of $350\,\text{mL}$, pale skin). Subjective data consist of unmeasurable thoughts, feelings, beliefs, and sensations reported directly by the patient (e.g., pain, itching, feeling weak, fear).

What is the distinction between primary and secondary data sources in nursing?

The care recipient is the sole primary data source. Secondary data sources encompass all other contributors, including family members, significant others, healthcare professionals, and medical records/documentation.

How do directive and non-directive medical history interviews differ?

A directive interview is highly structured and led by the nurse using closed questions to gather specific, factual information quickly (e.g., age, allergies, medical history). A non-directive interview uses open-ended questions and active listening, giving the patient freedom to share personal feelings, experiences, and concerns to build trust.

What four basic clinimetric parameters are standardly used to evaluate vital bodily functions?

1. Level of consciousness (alertness)
2. Respiratory rate (breaths per minute)
3. Oxygen saturation (binding of haemoglobin to oxygen)
4. Blood pressure (arterial pressure)

Which interprofessionally validated scoring systems are cited for assessing pain, pressure ulcer risk, and malnutrition?

Pain: VAS (Visual Analogue Scale) Pressure ulcer risk: Norton scale Screening for malnutrition: NRS (Nutrition Risk Screening)

What are the five steps and three key operational rules of the ABCDE approach?

Steps:

• A (Airway): Check patency, clear obstructions
• B (Breathing): Assess rate, symmetry, $SpO_2$, administer oxygen if needed
• C (Circulation): Pulse, blood pressure, capillary refill, bleeding
• D (Disability): AVPU scale or GCS, pupillary response, blood glucose
• E (Exposure): Undress to inspect skin, manage temperature, preserve dignity

Key Rules:

1. Treat first what kills first
2. Reassess constantly
3. Call for help early

Which international framework is shown in this diagram for systematically assessing how health conditions impact daily life and functioning?

The ICF model (International Classification of Functioning, Disability and Health), which assesses Body Functions and Structures (impairments), Activities (limitations), Participation (restrictions), Environmental Factors, and Personal Factors.

What are the eleven Functional Health Patterns compiled by nursing expert Marjory Gordon?

1. Health Perception and Health Management
2. Nutrition and Metabolism
3. Elimination
4. Activity and Exercise
5. Cognition and Perception
6. Sleep and Rest
7. Self-Perception and Self-Concept
8. Roles and Relationships
9. Sexuality and Reproduction
10. Coping and Stress Tolerance
11. Values and Beliefs

What does the acronym ISBARR stand for in clinical reporting?

ISBARR stands for:

• I: Identification
• S: Situation
• B: Background
• A: Assessment
• R: Recommendation
• R: Read Back

What information must be conveyed in the Situation (S) and Background (B) steps of ISBARR?

• Situation (S): The immediate problem or reason for the call (e.g., increasing shortness of breath since this morning).
• Background (B): Relevant admission context, medical history, and treatments (e.g., admitted three days ago with heart failure and receiving diuretics).

What information is communicated in the Assessment (A), Recommendation (R), and Read Back (R) components of ISBARR?

• Assessment (A): Objective clinical findings and observations (e.g., BP $85/55\,\text{mmHg}$, heart rate $120\,\text{beats per minute}$, pale and diaphoretic).
• Recommendation (R): The specific action or intervention requested (e.g., request for urgent assessment or medication adjustment).
• Read Back (R): Repeating back verbal orders or decisions to verify accurate mutual understanding.

Besides ISBARR, which other structured debriefing and handoff methods are commonly utilized in clinical practice?

1. SHIFT: Situation, History, Issues, Follow-up, and Tasks
2. SOAP: Subjective, Objective, Analysis, and Plan
3. ABCDE: Airway, Breathing, Circulation, Disability, Exposure/Environment

What are the eight basic principles that underpin all technical nursing procedures and care?

1. Hygiene and sterility
2. Safety
3. The care recipient's experience
4. Self-care and participation
5. Comfort
6. Ergonomics
7. Economy
8. Ecology

What are the three sequential stages of executing a technical nursing procedure?

1. Preparation
2. Execution
3. Follow-up

How are endogenous and exogenous healthcare-associated infections differentiated, and what is the diagnostic time threshold upon admission?

• Endogenous (auto-infection): Caused by microorganisms from the patient's own commensal flora becoming pathogenic due to an impaired immune system.
• Exogenous (cross-infection): Acquired from the healthcare environment, staff, or other patients.
• Infections manifesting within $48\,\text{hours}$ of admission are excluded as healthcare-associated, as they originated prior to admission.

What is the difference between transient skin flora and resident skin flora?

Transient (temporary) flora resides on the epidermis from environmental contact and is the primary driver of cross-infections; it is easily reduced by hand hygiene. Resident flora resides deep in the dermis, sebaceous glands, and hair follicles, functioning as normal commensal flora that can cause infection if introduced into sterile body sites.

According to scientific literature, what percentage of healthcare-associated infections can be prevented by targeted hand hygiene?

Approximately $30\%$ of healthcare-associated (nosocomial) infections can be prevented.

What are the 5 indications for hand hygiene during healthcare provision illustrated in this diagram?

1. Before patient contact
2. Before an aseptic/sterile procedure
3. After exposure to body fluids or risk thereof
4. After patient contact
5. After contact with patient surroundings

What specific personal hygiene rules must healthcare workers adhere to regarding nails, jewellery, and uniforms?

• Nails: Kept short (must not extend past fingertips), no artificial nails, nail polish, or nail piercings.
• Jewellery: No rings (including wedding rings), watches, bracelets, long earrings, or long necklaces.
• Uniform: Fresh uniform daily, short sleeves to expose wrists, washed at a minimum temperature of $60^\circ\text{C}$, and worn only on premises.

How are medical items classified into cleaning, disinfection, or sterilisation based on infection risk?

• Penetrates the skin barrier: Must be sterile (e.g., surgical instruments, needles, laparoscopes).
• Contacts mucous membranes or non-intact skin: Requires at least high-level disinfection (e.g., laryngoscopes).
• Contacts intact skin: Requires low-level disinfection and/or cleaning (e.g., blood pressure monitors), unless visibly soiled or used on infected patients.

What are the mandatory parameters for care recipient identification and the 5Ws of medication safety?

• Identification: Verified using at least two valid parameters (surname and first name, date of birth, barcode via ID wristband); room number or location must never be used.
• 5Ws Principle: Right care recipient, right medication, right dose, right time, right administration route.

What is the maximum fill capacity for a sharps container to prevent needlestick injuries?

A sharps/needle container must not be filled more than three-quarters ($\frac{3}{4}$) full.

What are the five illness belief themes outlined in Leventhal's Common Sense Model of self-regulation?

1. Identity ('What is wrong with me?')
2. Cause ('How did this develop?')
3. Timeline ('How long will this last?')
4. Consequences ('What are the consequences?')
5. Controllability ('How can I influence this?')

What is the distinction between self-reliance and self-management?

Self-reliance primarily concerns the physical ability to independently perform ADLs (activities of daily living) and IADLs (instrumental activities of daily living). Self-management extends beyond task performance to living a good, meaningful life and coping effectively with the broader consequences of an illness.

Which three pillars form the basic model for planning safe ergonomic patient transfers?

1. The care recipient (capabilities, limitations, natural range of motion)
2. The carer (body mechanics, balance, support structures)
3. Environmental factors (assistive devices, space, teamwork)

What defines a 'top-heavy posture' during manual patient handling, and why is it dangerous?

A top-heavy posture occurs when a worker bends their torso forward with straight legs so that a vertical line from the shoulder falls in front of the knees. It causes extreme pressure on the intervertebral discs, shifts weight to the forefeet, and tenses the entire posterior muscle chain to prevent falling.

What does the ergonomic 'three noses' rule require during patient repositioning?

The 'three noses'—the nose of the face and the two toes/tips ('noses') of the shoes—must all point in the exact same direction. This aligns the shoulder girdle with the pelvic girdle to eliminate torsion (twisting of the torso) during lifting.

What percentage of national emissions does the Belgian healthcare sector account for, and by how much are these emissions projected to rise by 2050?

The Belgian healthcare sector accounts for $5\%$ of national emissions, and emissions are projected to increase by $61\%$ by the year $2050$.