NSG 200 EXAM 1
SBARbn-bnanswers--S:bnSituationbn(patient'sbnbasicbninfo)
B:bnBackgroundbn(comorbidity,bnsocialbnfactors,bnallergies)
A:bnAssessmentbn(pertinentbnabnormalbnfindingbnfoundbninbnheadbntobntoebnassessment)
R:bnRecommendation(problemsbnwithbnthebnmostbnprioritybnfirst,bnanybnprecautions,bnandbnanybnisolati
ons)bn
*formbnofbncommunicationbnbetweenbnhealthbnpersonnel*
DARbn-bnanswers--D:bnDatabn(subjectivebnandbnobjectivebndata)
A:bnActionbn(documentbnallbnnursingbndata)
R:bnResponsebn(recordbnpatientsbnresponsebntobntherapy)bn
*formbnofbndocumentation*
SOAPbn-bnanswers--S:bnsubjectivebn(whatbnpatientbntellsbnyou)
O:bnobjectivebn(whatbnyoubnobservebnandbnsee)
A:bnAssessmentbn(whatbnyoubnthinkbnisbngoingbnonbnbasedbnonbnyourbndata)
P:bnplanbn(whatbnyou'rebngoingbntobndo)
Canbnalsobnbebnaddedbntobnbetterbnreflectbnnursingbnprocess:bn
I:bninterventionbn(specificbninterventionsbnimplemented)
E:bnevaluationbn(patient'sbnresponsebntobninterventions)
R:bnrevisionbn(changesbninbntreatment)
, *formbnofbndocumentation*
SubjectivebnDatabn-bnanswers--
whatbnthebnpersonbnsaysbnaboutbnthemselvesbn(biographicbnInformation,bnpastbnhistory,bnlifestyle,bnetc.
)
objectivebndatabn-bnanswers--
whatbnyoubnobtainbnthroughbnphysicalbnexaminationbn(posture,bnphysicalbnappearance,bnabilitybntobncar
rybnabnconversation,bnoverallbndemeanor,bnetc.)
PhasebnofbnInterviewbnprocess:bnIntroductionbn-bnanswers--
introducebnyourself,bnyourbnrole,bnexplainbnpurposebnofbnexamination,bnexplainbnhowbndatabnwillbnbebn
gatheredbnandbnused,bndiscussbnwithbnpatientbnotherbnpertinentbnmatters
Phasebnofbninterviewbnprocess:bnWorkingbn-bnanswers--gatherbndata,bnusebnopen-
endedbnquestionsbnwhichbnaskbnforbnnarrativebninformation,bnusedbnclosed/
bndirectivebnquestionsbnwhichbnaskbnforbnspecificbninformationbninshorebnone-twobnwordbnanswers.
*thisbnisbnwhenbncomprehensivebnandbnthebnhealthbnhistorybnisbngathered*
Phasebnofbninterviewbnprocess:bnClosingbn-bnanswers--
signalbninterviewbnisbnclosing,bnsummarizebnwhatbnyou'vebnlearned,bnreviewbndata/
bnmakebncorrections,bndiscussbnpossiblebnplansbntobnresolvebnsymptoms,bnanswerbnpatientsbnquestions/
bnconcerns
Communicationbntechniques:bninternalbnfactorsbn-bnanswers--
likingbnothers,bnexpressingbnempathy,bnabilitybntobnlisten,bnself-awareness
Communicationbntechniques:bnexternalbnfactorsbn-bnanswers--
ensurebnprivacy,bnpreventbninterruptions,bncreatebnabnconducivebnenvironment,bnequalbnstatusbnseating
,bnwearbnappropriatebnattire,bndocumentbnresponsebnwithoutbninterferingbnwithbnconservation
SBARbn-bnanswers--S:bnSituationbn(patient'sbnbasicbninfo)
B:bnBackgroundbn(comorbidity,bnsocialbnfactors,bnallergies)
A:bnAssessmentbn(pertinentbnabnormalbnfindingbnfoundbninbnheadbntobntoebnassessment)
R:bnRecommendation(problemsbnwithbnthebnmostbnprioritybnfirst,bnanybnprecautions,bnandbnanybnisolati
ons)bn
*formbnofbncommunicationbnbetweenbnhealthbnpersonnel*
DARbn-bnanswers--D:bnDatabn(subjectivebnandbnobjectivebndata)
A:bnActionbn(documentbnallbnnursingbndata)
R:bnResponsebn(recordbnpatientsbnresponsebntobntherapy)bn
*formbnofbndocumentation*
SOAPbn-bnanswers--S:bnsubjectivebn(whatbnpatientbntellsbnyou)
O:bnobjectivebn(whatbnyoubnobservebnandbnsee)
A:bnAssessmentbn(whatbnyoubnthinkbnisbngoingbnonbnbasedbnonbnyourbndata)
P:bnplanbn(whatbnyou'rebngoingbntobndo)
Canbnalsobnbebnaddedbntobnbetterbnreflectbnnursingbnprocess:bn
I:bninterventionbn(specificbninterventionsbnimplemented)
E:bnevaluationbn(patient'sbnresponsebntobninterventions)
R:bnrevisionbn(changesbninbntreatment)
, *formbnofbndocumentation*
SubjectivebnDatabn-bnanswers--
whatbnthebnpersonbnsaysbnaboutbnthemselvesbn(biographicbnInformation,bnpastbnhistory,bnlifestyle,bnetc.
)
objectivebndatabn-bnanswers--
whatbnyoubnobtainbnthroughbnphysicalbnexaminationbn(posture,bnphysicalbnappearance,bnabilitybntobncar
rybnabnconversation,bnoverallbndemeanor,bnetc.)
PhasebnofbnInterviewbnprocess:bnIntroductionbn-bnanswers--
introducebnyourself,bnyourbnrole,bnexplainbnpurposebnofbnexamination,bnexplainbnhowbndatabnwillbnbebn
gatheredbnandbnused,bndiscussbnwithbnpatientbnotherbnpertinentbnmatters
Phasebnofbninterviewbnprocess:bnWorkingbn-bnanswers--gatherbndata,bnusebnopen-
endedbnquestionsbnwhichbnaskbnforbnnarrativebninformation,bnusedbnclosed/
bndirectivebnquestionsbnwhichbnaskbnforbnspecificbninformationbninshorebnone-twobnwordbnanswers.
*thisbnisbnwhenbncomprehensivebnandbnthebnhealthbnhistorybnisbngathered*
Phasebnofbninterviewbnprocess:bnClosingbn-bnanswers--
signalbninterviewbnisbnclosing,bnsummarizebnwhatbnyou'vebnlearned,bnreviewbndata/
bnmakebncorrections,bndiscussbnpossiblebnplansbntobnresolvebnsymptoms,bnanswerbnpatientsbnquestions/
bnconcerns
Communicationbntechniques:bninternalbnfactorsbn-bnanswers--
likingbnothers,bnexpressingbnempathy,bnabilitybntobnlisten,bnself-awareness
Communicationbntechniques:bnexternalbnfactorsbn-bnanswers--
ensurebnprivacy,bnpreventbninterruptions,bncreatebnabnconducivebnenvironment,bnequalbnstatusbnseating
,bnwearbnappropriatebnattire,bndocumentbnresponsebnwithoutbninterferingbnwithbnconservation
