Intro to Nursing Exam 2 - Ross - Spring 2022
SBAR/I-SBAR-R - A structured way of relaying critical information in a spoken form.
Positives include reliability, promoting patient safety, and clear format. I-SBAR-R
replaced
I of I-SBAR-R - Introduction. Can easily be forgotten due to nerves. Include your name
and the patient you are taking care of.
S of I-SBAR-R - Situation. A quick summary of why the call is being warranted (high bp,
give data, etc.)
B of I-SBAR-R - Background. Give a quick overview of patient's history pertaining to
event (Ex. New onset of high blood pressure, becoming symptomatic with a bad
headache)
A of I-SBAR-R - Assessment. Explain what you are seeing (Ex. My assessment is
showing that his high blood pressure is why his headache pain has increased)
First R of I-SBAR-R - Recommendation. This can be a "scary" part, but so crucial. You
are the eyes for the physician. Tell them what you think could help or what you need
(Ex. Would it be possible to get some blood pressure medicine to help control this?)
Second R of I-SBAR-R - Read Back. Once you receive new orders, repeat back to
them. It's always good to verify as these conversations can happen so quickly (Ex.
'Order: IV labetalol 10mg. May repeat twice').
Professional Boundaries - the spaces between the nurse's power and the client's
vulnerability. The power of the nurse comes from the professional position and the
access to private knowledge about the client
Boundary violations - occurs when there is confusion between the needs of the nurse
and those of the client. Ask yourself this question: Could I feel comfortable telling a
colleague about my interaction with this patient?"
Zones of professional behavior - Under-involvement, Zone of helpfulness, and over-
involvement.
Under-involvement (Zones of Professional Behavior) - distancing yourself, showing
disinterest, neglect
Zone of helpfulness (Zones of Professional Behavior) - the ideal space or that area of a
therapeutic relationship
, Over-involvement (Zones of Professional Behavior) - sharing personal information by
the nurse, secrecy, touching, gestures, money or gifts, sexual misconduct
Consequences of professional boundary violations - Violation of nursing code of ethics,
Reportable offense shared with your state board of nursing, Employer involvement,
and/or Possible termination
Phases of Nurse-Patient Relationships - Orientation, working, and termination. Has to
be started first and foremost prior to any other steps can. Begin in the nursing process.
Orientation (Nurse-Patient Relationship) - The "getting to know you" phase. Establishing
trust is crucial. First impressions can set the tone of how the relationship will be. Outline
and explain the activities ahead
Working phase (Nurse-Patient Relationship) - The portion of which you conduct what
you laid out for in the orientation phase. Patients may exhibit some periods of resistance
to change (Ex. Someone getting a new diagnosis of congestive heart failure). Work
through this with your patient, continue to be encouraging, promote active listening and
focus on continuing building of trust.
Termination (Nurse-Patient Relationships) - The activities that enable the nurse and
patient to end their relationship, but making sure it's done in a therapeutic manner (Ex:
Discharge after outpatient surgery or patient out of hospital).
Levels of communication - Verbal, Nonverbal, Congruent, and Incongruent
communication.
Verbal Communication - Consists of speech (obvious form)
Nonverbal Communication - Used the most when someone portrays a message. Facial
expressions, clothing, grooming, eye contact, People are less likely to mask their
nonverbal versus their words.
Congruent Communication - When verbal and nonverbal communication match and
reinforce each other
Incongruent communication - When verbal and nonverbal communication do not match
each other. Can create confusion. (Ex. "I'm fine").
Common law - judge rulings become law; body expands as make legal decisions
Statutory law - Laws that have particular importance for nurses-state laws or statutes to
practice; licensing standards for professions
Administrative law - Law where legislature delegates authority to government agencies
to create laws
SBAR/I-SBAR-R - A structured way of relaying critical information in a spoken form.
Positives include reliability, promoting patient safety, and clear format. I-SBAR-R
replaced
I of I-SBAR-R - Introduction. Can easily be forgotten due to nerves. Include your name
and the patient you are taking care of.
S of I-SBAR-R - Situation. A quick summary of why the call is being warranted (high bp,
give data, etc.)
B of I-SBAR-R - Background. Give a quick overview of patient's history pertaining to
event (Ex. New onset of high blood pressure, becoming symptomatic with a bad
headache)
A of I-SBAR-R - Assessment. Explain what you are seeing (Ex. My assessment is
showing that his high blood pressure is why his headache pain has increased)
First R of I-SBAR-R - Recommendation. This can be a "scary" part, but so crucial. You
are the eyes for the physician. Tell them what you think could help or what you need
(Ex. Would it be possible to get some blood pressure medicine to help control this?)
Second R of I-SBAR-R - Read Back. Once you receive new orders, repeat back to
them. It's always good to verify as these conversations can happen so quickly (Ex.
'Order: IV labetalol 10mg. May repeat twice').
Professional Boundaries - the spaces between the nurse's power and the client's
vulnerability. The power of the nurse comes from the professional position and the
access to private knowledge about the client
Boundary violations - occurs when there is confusion between the needs of the nurse
and those of the client. Ask yourself this question: Could I feel comfortable telling a
colleague about my interaction with this patient?"
Zones of professional behavior - Under-involvement, Zone of helpfulness, and over-
involvement.
Under-involvement (Zones of Professional Behavior) - distancing yourself, showing
disinterest, neglect
Zone of helpfulness (Zones of Professional Behavior) - the ideal space or that area of a
therapeutic relationship
, Over-involvement (Zones of Professional Behavior) - sharing personal information by
the nurse, secrecy, touching, gestures, money or gifts, sexual misconduct
Consequences of professional boundary violations - Violation of nursing code of ethics,
Reportable offense shared with your state board of nursing, Employer involvement,
and/or Possible termination
Phases of Nurse-Patient Relationships - Orientation, working, and termination. Has to
be started first and foremost prior to any other steps can. Begin in the nursing process.
Orientation (Nurse-Patient Relationship) - The "getting to know you" phase. Establishing
trust is crucial. First impressions can set the tone of how the relationship will be. Outline
and explain the activities ahead
Working phase (Nurse-Patient Relationship) - The portion of which you conduct what
you laid out for in the orientation phase. Patients may exhibit some periods of resistance
to change (Ex. Someone getting a new diagnosis of congestive heart failure). Work
through this with your patient, continue to be encouraging, promote active listening and
focus on continuing building of trust.
Termination (Nurse-Patient Relationships) - The activities that enable the nurse and
patient to end their relationship, but making sure it's done in a therapeutic manner (Ex:
Discharge after outpatient surgery or patient out of hospital).
Levels of communication - Verbal, Nonverbal, Congruent, and Incongruent
communication.
Verbal Communication - Consists of speech (obvious form)
Nonverbal Communication - Used the most when someone portrays a message. Facial
expressions, clothing, grooming, eye contact, People are less likely to mask their
nonverbal versus their words.
Congruent Communication - When verbal and nonverbal communication match and
reinforce each other
Incongruent communication - When verbal and nonverbal communication do not match
each other. Can create confusion. (Ex. "I'm fine").
Common law - judge rulings become law; body expands as make legal decisions
Statutory law - Laws that have particular importance for nurses-state laws or statutes to
practice; licensing standards for professions
Administrative law - Law where legislature delegates authority to government agencies
to create laws
