NCSBN NCLEX-PN review – Flashcards

determined by state's Nurse Practice Act

established by the nursing profession i.e. American Nurses Association

institutional policy and procedure documents

*S*ituation = a concise statement of the problem *B*ackground = pertinent and brief information related to the situation *A*ssessment = analysis and consideration of options - what you found/think *R*ecommendation = action requested/recommended - what you want

*I*ntroduction = introduce yourself and your role/job *P*atient = name, identifiers, age, gender, location *A*ssessment = presenting chief complaint, vital signs and symptoms and diagnosis *S*ituation = current status/circumstances, including code status, recent changes, response to treatment *S*afety concerns = critical lab values/reports, socio-economic factors, allergies, alerts such as falls, isolation, etc. *B*ackground = co-morbidities, previous episodes, current medications, family history *A*ctions = what actions were taken or are required and provide brief rationale *T*iming = level of urgency and explicit timing, prioritization of actions *O*wnership = who is responsible - nurse/doctor/team and patient/family responsibilities *N*ext = what will happen next? anticipated change? what is the PLAN? what is the contingency plan?

1. Right Task 2. Right Circumstances 3. Right Person 4. Right Direction/Communication 5. Right Supervision/Evaluation

*1. Clear* - Does the team member understand what I am saying? *2. Concise* - Have I confused the direction by giving too much unnecessary information? *3. Correct* - Is the direction given according to policy, procedures, job description, and the law? *4. Complete* - Does the delegatee have all the information necessary to complete the task?

A= Assessment D= Diagnosis P= Planning I= Implementation E= Evaluation

*C*onfidential *O*rganized (chronologically) *A*ccurate *C*omplete *T*imely *S*ubjective and objective data

*S* = subjective; what client tells you *O* = objective; what you observe, see, etc. *A* = assessment; what you think is going on based on the data *P* = plan; what you are going to do

*D* = data - collecting information about a problem *A* = action - the task to be completed about the problem *R* = response - the client's response to the problem

*A* = assessment *P* = problem *I* = intervention *E* = evaluation

1. assessment 2. nursing diagnosis and client needs 3. interventions 4. care provided 5. client response to care 6. client's ability to manage continuing care after discharge

identifies what a client wishes for his care should he become unable to communicate these wishes

the client has appointed a person to make decisions about their care if they are unable to do so

this has been expanded to include identification of medications that may be given without any defibrillation attempts (comfort measures only)

*Class A* Ordinary combustible materials, such as paper, wood, cardboard, and most plastics *Class B* Flammable or combustible liquids, such as gasoline, kerosene, grease, and oil *Class C* Electrical equipment, such as appliances, writing, circuit breakers and outlets *Class D* Chemical laboratories; for fires that involve combustible metals, such as magnesium, titanium, potassium and sodium

*P*rotect clients from injury *R*eport the fire *C*ontain the fire

*R*escue or remove clients *A*ctivate fire alarm system *C*ontain fire by closing doors and windows *E*xtinguish flames (with fire extinguisher)