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Nursing 20 - Assessment systems
Nursing 20 - Assessment systems
Nursing 20 - Assessment systems

Nursing 20 - Assessment systems - Exercises

sistemas de evaluación

Exercise 1: Match a word

Instruction: Match each word with its definition.

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La Escala Numérica de Dolor (NRS): Escala del 0 al 10 para medir la intensidad del dolor. (The Numeric Rating Scale for Pain (NRS): Scale from 0 to 10 to measure the intensity of pain.)
Un indicador no verbal: Señal sin palabras que indica dolor o malestar en el paciente. (A nonverbal indicator: Signal without words that indicates pain or discomfort in the patient.)
La comunicación estructurada SBARR: Método para informar un caso de forma clara y ordenada al equipo. (The structured SBARR communication: Method to report a case clearly and in an organized manner to the team.)

Exercise 2: Exam preparation (QR: Audio)

Instruction: Read the text, fill in the gaps with the missing words, and answer the questions below

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Nota interna: valoración del dolor y comunicación SBARR

Fill in the gaps: Gordon, observación, localización, SBARR, OMS, indicadores, resultado

(Internal note: pain assessment and SBARR communication)

Para unificar la valoración del dolor en planta, el servicio recomienda usar la Escala Numéricajunto con la observación de no verbales. Además de la intensidad, se debe registrar la , y los factores que empeoran o alivian el dolor, así como el esperado tras la intervención. Si el paciente no puede hablar, la debe anotarse de forma clara.

En el pase de guardia se solicita estructurar la información con : situación, antecedentes, valoración, recomendación y respuesta esperada. Para el plan de cuidados se puede orientar la entrevista con los patrones funcionales de y, de forma general, recordar la clasificación de la y el enfoque de Salud Positiva, que incluye bienestar y resiliencia.
To standardize pain assessment on the ward, the service recommends using the Numeric Rating Scale (NRS) together with the observation of nonverbal indicators (facial expression, posture, restlessness). In addition to intensity, the location should be recorded, as well as the factors that worsen or relieve the pain, and the expected outcome after the intervention. If the patient cannot speak, the observation should be clearly documented.

During handover, it is requested to structure the information with SBARR: situation, background, assessment, recommendation, and expected response. For the care plan, the interview can be guided with Gordon’s functional patterns and, in general, remember the WHO classification and the Positive Health approach, which includes well-being and resilience.

  1. ¿Cómo aplicarías la NRS y los indicadores no verbales en un paciente con movilidad reducida y qué datos incluirías en un SBARR?

    (How would you apply the NRS and nonverbal indicators in a patient with reduced mobility and what data would you include in an SBARR?)

Exercise 3: Listening

Instruction: Listen to the audio and answer the questions.

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(During today’s ward round I had to assess the pain of an elderly patient. First I used the Numeric Rating Scale for Pain, the NRS, and she said 7; I also observed nonverbal indicators: a tense facial expression and reduced mobility. Then I reviewed Gordon’s Functional Health Patterns, especially the sleep and rest patterns and the activity and exercise pattern. In the report I followed the SBARR method: I stated the situation, reported the background, and advised a plan. I wrote down the expected outcome and linked it to the WHO Classification.)
True False

(In addition to asking about the NRS, the professional interpreted nonverbal signs to estimate the pain.)

(To complete the assessment, she focused only on the WHO Classification and did not consult the functional history.)

(In her structured communication, she proposed a plan and recorded what the expected outcome was.)

Exercise 4: Multiple Choice

Instruction: Choose the correct solution

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1. En urgencias, primero ___ el dolor con la Escala Numérica de Dolor (NRS) y luego lo registramos en la historia clínica.

(In the emergency department, we first ___ pain with the Numeric Rating Scale (NRS) and then record it in the medical record.)

2. Si el paciente no puede hablar, ___ indicadores no verbales como la expresión facial y la movilidad reducida.

(If the patient cannot speak, ___ nonverbal indicators such as facial expression and reduced mobility.)

3. Ayer, durante el turno de tarde, ___ la situación al médico usando el método SBARR.

(Yesterday, during the afternoon shift, ___ the situation to the doctor using the SBARR method.)

Exercise 5: Dialogue Cards

Instruction: Practice the conversation with your teacher or fellow students.

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Traspaso de paciente en urgencias

Exercise 6: Discussion questions (QR: AI+)

Instruction: Speaking: translate and respond (QR: AI+)

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Useful expressions:

Según la NRS, el dolor es de… sobre 10. / He observado que… y lo he anotado en la historia clínica. / La situación es…; como recomendación, sugiero…

  1. En una consulta, ¿cómo valorarías el dolor de un paciente con la escala numérica (NRS) y qué dato adicional anotarías además del número?
    In a consultation, how would you assess a patient’s pain with the numeric rating scale (NRS) and what additional information would you record besides the number?

    __________________________________________________________________________________________________________

  2. Debes informar a un médico usando SBARR: ¿qué dirías brevemente sobre la situación y qué recomendación darías según tu observación del paciente?
    You must report to a doctor using SBARR: what would you briefly say about the situation and what recommendation would you give based on your observation of the patient?

    __________________________________________________________________________________________________________

Exercise 7: Writing correspondence (QR: AI+)

Instruction: Write a reply to the following message appropriate to the situation

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Asunto: Traspaso - Hab. 312 (Sr. López)

Hola, Marta:

Te hago un traspaso rápido antes del cambio de turno. Situación: el Sr. López (posoperatorio de hernia, hoy) refiere dolor abdominal NRS 7/10 desde hace 1 hora.

Antecedentes: sin alergias conocidas. Se le dio paracetamol a las 18:00. No ha dormido bien. Indicadores no verbales: cara tensa, se protege la zona al moverse.

Evaluación: constantes estables. Herida seca.

Recomendación: reevaluar dolor en 30 min y avisar al médico si sigue ≥7. ¿Puedes hacer el control y registrarlo?

Gracias,
Laura (Enfermería)

Subject: Handover - Room 312 (Mr. López)

Hi, Marta:

I’m sending you a quick handover before the shift change. Situation: Mr. López (post-op hernia repair, today) reports abdominal pain NRS 7/10 for the last 1 hour.

Background: no known allergies. He was given paracetamol at 18:00. He hasn’t slept well. Non-verbal indicators: tense face, guards the area when moving.

Assessment: vitals stable. Wound dry.

Recommendation: reassess pain in 30 min and notify the doctor if it remains ≥7. Can you do the check and document it?

Thanks,
Laura (Nursing)

Useful phrases:

  1. Según lo que me comentas, la situación es...

    (Based on what you’ve told me, the situation is...)

  2. ¿Me puedes confirmar si...?

    (Can you confirm whether...?)

  3. Propongo que hagamos lo siguiente: ...

    (I propose that we do the following: ...)

Hola, Laura:

Gracias por el traspaso. Entendido: Sr. López, hab. 312, posoperatorio de hernia con dolor abdominal NRS 7/10 desde hace una hora; presenta cara tensa y se protege al moverse. Antecedentes: sin alergias y paracetamol a las 18:00; además ha descansado mal.

¿Me confirmas si el dolor es continuo o aparece sobre todo al moverse, y si tiene náuseas o fiebre? Ahora paso a valorarlo (localización e intensidad con NRS) y lo registro en la hoja de enfermería. Lo reevaluaré en 30 minutos y, si persiste en 7 o más o empeora, aviso al médico de guardia siguiendo SBARR.

Un saludo,
Marta
Hi, Laura:

Thanks for the handover. Understood: Mr. López, room 312, post-op hernia repair with abdominal pain NRS 7/10 for the last hour; he has a tense facial expression and guards when moving. Background: no allergies and paracetamol at 18:00; also, he has rested poorly.

Can you confirm whether the pain is continuous or mainly occurs when moving, and whether he has nausea or fever? I’ll go assess him now (location and intensity using NRS) and document it in the nursing notes. I’ll reassess in 30 minutes and, if it persists at 7 or more or worsens, I’ll notify the on-call doctor following SBARR.

Best regards,
Marta