Module 1 Assignment Subjective Data (interview guide) and Objective data: General status, Vital Signs, Pain, Nutrition. SBAR.

NURS 3315 Holistic Health Assessment

Module 1 Assignment
Subjective Data (interview guide) and Objective data: General status, Vital Signs, Pain, Nutrition. SBAR.

The quizzes are open from the first day of class. But they close on the weekend (Sunday night at 2359) of the week to which they belong—see the class schedule for the dates and to get the composite view of all the assignments and weeks.
Submit assignments by 2359 Saturday of the week in which Module 1 is covered.
In this assignment, you will find an adult person from whom to collect holistic health assessment data –you may use a different person for each week if you would like. I recommend, for instance, using a person with known COPD for the week that covers respiratory assessment. If you know someone who has neurological deficits, assess him/her the week we cover the neuro system—it will make your data collection a lot more interesting than if you use a perfectly healthy person with no abnormal findings! Some of you may not have access to a spectrum of people, so assess whomever you feel you can, keeping in mind that the more health issues they have, the more varied findings you have the opportunity to assess.
Use the physical assessment data forms for the topics we are covering, filling in the forms provided. These have been adapted from the Lippincott lab manual, with permission. For this first module, you will fill out the guides from the following chapters:
1. Assessing General Status and Vital Signs
2. Assessing Pain
3. Assessing Nutritional Status
Note: N/A, Normal/WNL, “within normal limits”, and “good” are not acceptable as assessment findings. For this class, you must state what the finding is—describe it. Your textbook will demonstrate use of a number of descriptors. This is, after all, an assessment class, and making certain our students can easily use all terminology is one of our goals.
All assessment procedures must be completed unless otherwise instructed, even if your patient has completely normal findings. This is your time to practice and learn these techniques based on information provided in the weekly text book readings-use your text book as a guide when completing assessment forms. You may use the same wording you see in the book, if you feel it is best. Please refer to the sample assignment provided in the course resources so you understand the expectations for format. This is time consuming; plan to complete the assignment in detail.
Plagiarism when filling out the assessment forms: Usually not an issue if you are describing a real person and not reproducing another person’s paper.
I would like to address the topic of plagiarism for this class—if you assess a real patient and describe your findings in appropriate nursing terminology, using phrases rather than whole sentences—plagiarism is not typically an issue. (Of course, if you just copied someone else’s work it would be! It would show up as verbatim work since all your work will be submitted through SafeAssign, our plagiarism monitoring tool.) I am not interested in you finding original ways to say things to avoid plagiarism—just state (for instance) “Denies pain”, or (in the Physical Development portion of the form below) “Development is appropriate for sex and age”. You can see it is ordinarily not an issue in this class! You may be using those well-established phrases such as “Respirations even and unlabored.” Don’t try to turn it into the Great American Novel and say it more creatively just so your word utilization will be different. One student described a patient’s affect by saying, “He had a dark and stormy countenance.” Just saying he appeared angry because the physician was late would have been concise and direct without being flowery, or as they used to say, “Going all Jane Austin.” Some specific phrases have been used in a standardized way in describing various systems, and we will expect to see those on the SafeAssign report. But if a more-than-expected proportion of your work is flagged, and we see that the work was copied, will we be forced to consider the possibility of academic dishonesty.
Note that in this class you MAY NOT conduct assessments of the breast, female/ male genitalia, rectum, anus or prostate during your physical assessments.
SBAR Overview
The student will write an SBAR: A short concise statement of:
Situation
Background
Assessment
Recommendation
The SBAR will cover the situation that seems most urgent from the subjective and objective data collection exercises. In a healthy young person, this may a health promotion situation rather than a current condition.
For instance, while conducting the subjective or objective data collection you may notice that your patient has no current pathology, but their habits cause them to be at risk for a problem in the future. If you assess a healthy young professional, perhaps a female nurse, and find that she eats fast food 5 – 6 times per week (and that is the most serious finding in the whole assessment), your SBAR might address the potential for consequences of a high-fat, low nutrient diet. (You don’t actually have to share your SBAR with the patient—she might not appreciate a lecture from you on the way she eats. On the other hand, if you think it would be helpful for her to see, and you feel she might benefit, go ahead and share it.)
Everyone has had pain of some sort. If pain is the most urgent of their present or past health needs, as evaluated by you and the patient, write an SBAR about this problem. In the hospital setting we use SBAR to help us organize our thoughts and to make sure we have obtained all the pertinent information needed before making a call to the physician or nurse practitioner. It is a way of allowing us to have a moment to make sure we fully understand the situation and the implications of what is happening before we go about explaining it to someone else.
An example of an SBAR is available under Resources. I give a fuller explanation of what an SBAR is and how to use it below, for those who want to know more. (Some of you have been using it for years and may not need to read to my introductory comments, which are located below the rubric.)
Submitting your assignment
Many students have found the best way to organize is to make a new folder in Word for this class.
• Save this document to your computer in the Health Assessment folder as a Word document.
• Open the document from your computer and type your information directly into the assignment areas provided on the template.
• When you are finished, find the SafeAssign upload portal in the Module 1 section for this assignment, and upload it there.
Rubric
Use this rubric to guide your work from the Module 1 objective data assignment.
Excellent Good Needs Work Needs extensive work Clearly incomplete
Use of specifically prohibited terminology 10 points Uses no vague terms such as good, normal, N/A or not applicable 0 to 9 points Subtract 1 percentage point per incorrect term up to 10 points.
Assessment descriptions 30 to 39
points 0 to 29 points
50 points 45 to 49 points
40 to 44 points Several Most
All descriptions 1 – 5
6 to 10 or more areas are descriptions
are appropriate descriptions that descriptions are incomplete, are incomplete
and complete, are not incomplete or or more than or more than 4
capturing complete, or an two areas are 2-4 areas are areas of the
important aspects area is missing/blank. missing assessment
of health status missing/blank. information/blare blank. ank.
Grammar 5 points Short sentences or phrases are used, no grammatical errors. 3 to 4 points One to two grammatical errors 1 to 2 points three to four
grammatical errors 0 to 0 points Five or more
grammatical errors
SBAR Situation 5 to 5 points
Situation or 3 to 4 points
Situation is too 1 to 2 points
Vague, not 0 to 0 points
Missing
current problem is well-described, brief and the current problem is identified. wordy or too brief, not as clearly identified as it should be. correctly done.
SBAR Background 0 to 3 points
6 to 7 points Missing 10 points 8 to 9 points 4 to 5 points
Information given altogether or
Background gives Background too Few relevant is vague or some poorly
pertinent data wordy or too data are pertinent data is executed so
about patient’s brief, but given or missing, some that
health status and captures format not relevant data background
history. pertinent data. followed.
present. cannot be
understood.
SBAR Assessment 10 points
Assessment names the trouble in a word or phrase that briefly captures the problem. The statement may include a lab or physical finding. 8 to 9 points This entry is too wordy and cites things that belong in situation or background, in addition to capturing the problem. 6 to 7 points
The problem is stated too briefly to be clear. 4 to 5 points Problem is not synthesized correctly. 0 to 3 points Missing or incorrect.
SBAR Recommendation 10 to 10 points Recommendation
is appropriate for the situation. 5 to 9 points Recommendatio
n lacks merit but is still relevant. 0 to 4 points Recommendatio
n is present but is incorrect.

Performance Objectives:
• Collect subjective and objective data to include present health concerns, past health history, family history and lifestyle/health practices related to:
o Collect biographical data. o Collect nutritional data. o Collect general status data.
o Write assessment data in a complete manner
o Write an SBAR addressing one problem each week in a focused and informative way.

Optional supplementary information regarding the SBAR

Do your remember calling a doctor about a patient, early during the first few days or weeks after you became a nurse? I do. I still cringe when I think of it. I worked on a pediatric intensive care unit, and the patient’s urine output had fallen to less than 10 ml per hour, for 2 hours. The foley was draining without a problem, the problem was the urine output. Why I called before getting all the information, I don’t know—I was just new and didn’t think the situation out clearly, I guess. I was so focused on the urine output, I didn’t think about all of the surrounding pertinent info—the latest lab results, for instance, and the fluid balance for the last few hours. When I called the doc, of course he asked me about the sodium and potassium. I had to go look it up. He asked about the urine output for the last few shifts, and…I had to look it up. I had called with no other information in hand except vital signs and low urine output, and I expected to get orders to remedy the situation. It sounds so ridiculous now!
I have since enjoyed 30 years in the profession, spending more than 10 years in critical care before breaking into women’s health and becoming a nurse practitioner. I have oriented many new nurses, and can attest that many of them become overwhelmed and stressed and deal with new situations in as unproductive a manner as I did. (This was 30 years ago—now, with much better internships, hopefully no new nurse would be in this sort of situation unsupervised. Many new nurses today DO, however, struggle with calling physicians about patient problems—so that part of the problem remains similar.) We “live and learn”, as they say! If I had used the SBAR format, I would have saved myself from an excessively embarrassing situation! I only made that mistake once…. As experienced nurses, you will be in a position to orient new graduates. Be kind—we were all new once! If you direct your new coworkers toward this tool and model its use to them, you will be helping them progress more quickly toward competency.
What is SBAR?
SBAR stands for Situation, Background, Assessment, and Recommendation. On a U.S. Navy nuclear submarine, a young ensign used the newly-developed SBAR format to report a potentially dangerous situation to his top supervisor, the commander of the ship. The young man eventually became a nurse, and he has written about this experience in a journal article
(Heinrichs, Bauman, & Dev, 2012). He felt that the SBAR style of communication “flattened the hierarchy” between an inexperienced- yet-well-trained beginner, and the all-important commander of the ship, who needed information the young man possessed.
The format works so well that it is being used in aviation and health care. SBAR is
gaining in popularity and in this class will be used instead of nursing diagnoses for categorizing and meeting patient needs and as a pattern for communicating with other members of the healthcare team. The Joint Commission for Accreditation of Hospitals has listed Standardized Communication to its Patient Safety Goals and recommends the use of SBAR as a means of increasing effectiveness of patient care and safety.
Some nurses think it is just a new and inconvenient fad in health care (see the AllNurses website), yet actually, most of us have been using it for years—we just didn’t have a name for it. Now, the same procedure that we older nurses learned through hard experience, (after a couple of embarrassing phone calls), brand new nurses and students are learning in school.

Here is an example of how that SBAR would have sounded in use:
“Dr. Smith, this is Deana Furr. I am caring for Jane Doe, age 16, the patient Dr. Jones admitted this afternoon with loss of consciousness on the ball field.
Situation: Her urine output has been 5 – 7 ml. for the last 2 hours.
Background: She has been in good health, though underweight, until today. When she was out with her high school class in P.E., she fell and lost consciousness for about 5 minutes. Paramedics were called and she was admitted about 1 PM. She awakened in the ambulance, and was given fluids. She went for a CT scan, which was normal. Her BUN is 18, Creatinine is 1.0. Na is 42, K is 4.8. D51/2NS is going at 50 ml/hr. She is on a general diet but has taken nothing by mouth except ice chips—we can’t get her to drink. Assessment is normal except she is awfully thin—she weighs 98 lbs, and she is 5 feet 5 inches. Her mother was here initially, but left once she woke up, to get her younger children from school.
Assessment: (If I had been an experienced nurse, I might have ventured to say that she was dehydrated, but at this point I was only prepared to say that I was calling because her urine output was low. I should have had someone looking over my shoulder to advise me, but for some reason, no one was. …and for some reason I was too stressed by what was happening with my other patient to recognize a simple problem.)
Assessment (for the experienced nurse): “I believe she is dehydrated.”
Recommendation: The template states you should make a recommendation—you must do so to get full credit for the assignment. Of course, in real life if you are in a complex situation you may or may not know what needs to be done next. Sometimes I have thought in my mind,
“I don’t know how you are going to fix this—that’s why you’re the physician and make the big bucks! You’ve been trained for this sort of situation and I haven’t!” Of course, since you won’t be saying that, a good thing to say is: “How would you like to proceed?” (That is what I did in the situation I mentioned above, and in my inexperience, it had the merit of being practical. You have your own methods of communicating with the clinicians at your facility.) I got an order for a fluid bolus of 500 ml over 1 hour and to call if the urine output wasn’t higher by the next hour. It wasn’t higher and I ended up calling and getting an order for another fluid bolus. After that the patient improved. The doctor was planning to be on the unit as soon as he could, but figured it would be a couple hours.
FOR THIS CLASS, under the R section, make a RECOMMENDATION. You are
assessing a friend or family member that is not in the hospital—you probably can’t do an SBAR on a STAT situation, but just tell me what needs to happen next in dealing with the problem. For example, if the patient is healthy and all you can come up with for SBAR is some minor problem, then you might say, “I recommend that the patient address this problem with her nurse practitioner at her next annual physical exam.” Maybe there are no urgent health problems but the patient drinks 3 – 4 sodas per day or gets no exercise. Make a recommendation that the patient change his behavior to decreasing intake of sugary drinks to 1 or less per day, or begins walking for a few minutes daily, increasing to 30 minutes three times per week. Perhaps your assessment buddy has blood pressure problems and his current BP is 164/92. That is too high. Your buddy may not need to go to the ER about it, but under R
(Recommendation) you could put: “I recommend that the patient make an appointment for this coming week with his physician to address this.”
Maybe you are assessing your grandmother who has occasional arthritis pain in her hands. Your recommendation might be that she use over-the-counter naproxen a couple of times a week with food, following the directions on the bottle and addressing the problem with her clinician at her next appointment. (Assuming that you know she has no health problems or other medication usage that would conflict with this.)
Why we need SBAR
One of the long-standing problems at the root of communication issues between nurses and doctors (especially among new nurses and doctors) is the fact that doctors are trained to be concise and get to the bottom of the problem quickly, while nurses are taught to be descriptive and to look at the patient holistically—to see the big picture. Physicians have complained for years that new nurses have a hard time getting to the point when they call. Perhaps you are not a new nurse. The tool is still useful since SBAR gives us a standard format. If doctors want more information than we give them initially, they can always ask for more. Current studies confirm that SBAR makes communication quicker, more focused, more consistent, and gets results more consistently, among nurses with little and with much experience (Cornell, Gervis, Yates & Vardaman, 2014; Pope, Rodzen & Spross, 2008). Here are a couple of websites that give further examples of SBAR use in various situations:
http://www.champ-program.org/static/Entire_SBAR_Package.pdf http://www.saferhealthcare.com/sbar/what-is-sbar/

References
Cornell, P., Townsend Gervis, M., Yates, L., & Vardaman, J. M. (2014). Impact of SBAR on Nurse Shift Reports and Staff Rounding. MEDSURG Nursing, 23(5), 334-342.
Heinrichs, W., Bauman, E. Dev, P. (2012). SBAR ‘flattens the hierarchy’ among caregivers.
Studies in Health Technology and Informatics 2012(173), 172-185, doi: 10.3233/978-161499-022-2-175
Pope, B., Rodzen, L, & Spross, G. (2008). Raising the SBAR: How better communication improves patient outcomes. Nursing, 38(3), 41-43.
doi: 10.1097/01.NURSE.0000312625.74434.e8