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Key terms U-2

Fundamentals

TermDescription
Inspection is the process of performing deliberate, purposful observations in a systemic manner.
Palpation is an asssessment technique that uses the sense of touch. The hands/fingers can asses temperature, turgor, texture, moisture, vibrations, and shape.
The dorsum (Back) of the had is used for gross measure of temperature.
The palmer (frount) surface of the hand is used for assessing texture, shape fluid, size, consistency, and pulsation. Vibrations is best felt with the palm of the hand
Percussion is the act of striking one object against another to produce sound. Used to assess the location, shape, size, and density of tussues.
Ausculation is the act of listening with a stethoscope to sounds produced within the body.
Erythema Redness of the skin. Most often seen in face and neck
Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxgyenation
Jaundice is a yellow color of the skin resulting from liver and gallbladdr disease, some types of anemis, and hemolysis Usually developes first in the eyes.
Pallor paleness of th skin, often from inadequate amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues.
Ecchymosis is a collection of blood in the subctaneous tissues, causing purplish discoloration.
Petechiae are small hemorrhagic spots caused by capillary bleeding. If present asses location, color, and size
Turgor is the fullness or elasticity of the skin and is usually assessed on the sternum or under the clavicle. Normal=the elasticity of the skin picked up returns to normal. When pt is dehydrated, the skin slowly returns to normal.
Edema ixcess fluid in the tissues. Swelling taut and shiny skin over the edematous area.
Pitting edema when the area of the edema is palpated with the fingers, an indentatin may remain after the pressure is relased.
Bronchial sounds are heard over the trachea are high pitched, harsh sounds, with expiration being longer than inspiration
Bronchovesicular sounds are heard over the mainstem bronchus and are moderate "blowing" sounds with inspiration equal to expiration
Vesicular breath sounds are soft, low pitched sounds, heard best over the base of the lungs during inspiration, which is longer than expiration
Adventitious breath sounds are not normally heard in the lungs but, if present may be ausculated along with normal breath sounds
Precordium anterior surface of the chest wall overlying the heart and its related structures. The aortic, pulmonic, tricuspid, and spical areas, and Erb's point.
Bruits normal "swooshing" sounds similar to murmurs and are heard over major blood vessles. It indicate a partially blocked or over extended artery, causing blood to swirl rather than flow normaly
nursing process is a systematic method that directs the nurse and pt as together they acomplish: assess, nursing diagnoses, expected outcome, plan, implementation, and evaluateion.
Assessing systematically collect pt data
Diagnosing Clearly identify pt strengths and actual and potential problems
Planning is to develope a holistic plan of individualized care that specifies the desired pt goals and related outcomes and the nursing interventions most likely to assist the pt to meet those expected outcomes
Implementing Execute the plan of care
Evaluating Evaluating the effectiveness of the plan of care in terms of pt goal achievment
Trial-and-error problem solving involves testing any number of solutions until one is found that works for that particular problem. Not efficient/dangerous/not recomended
Scientific problem solving is a systematic, seven step problems solving process. Id problem, collect data, hypothesis formulaiton, plan of action, test hypothesis, interpurt results, evaluate results.
Intutive thinking flashes of intuition
Cognitively skilled a nurse that thinks about the nature of things sufficiently to make sense of their world and to grasp conceptually what is necessary to achieve valued goals.
Critical thinking a systematic way to form and shape one's thinking, It is disciplined, comprehensive, based on intellectual standards, and well reasoned.
Technically skilled nurse that is able to manipulate equipment skillfully to produce a desired outcome or result.
Interpersonally skilled a nurse that is able to establish and maintain caring relationships that facilitate the achievevment of valued goals while simultaneously affirming the worth of those in the relationship.
Ethically and legally skilled a nurse that can conduct themselves in a manner consistent with their personal moral code and professional role responsibilities
Standards for critical thinking clear, precise, specific, acurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair.
Whistle blowing refers to an employee who reports thier employer's violation of the law to appropriate law enforcement agencies outside the employer's facilities.
Assessing is the systemic and continous collection, validation, and communication of pt data
Data information
Database all the pertinent information that enables a comprehensive and effective plan of care to be designed and implemented for the pt
Initial assessment is performed shortly after the pt is admitted to a healthcare agency or service
Focused assessment the nurse gathers data about a specific problem that has already been identified.
Emergency assessment To identify lifethreatening problems
Time-lasped assessment is scheduled to compare a pt current status to baseline datat obtained earlier
Minimun data set a standard established by most schools of nursing and healthcare institutions that specifies the information that must be collected for every pt
Objective data observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
Subjective data is information pereceived only by the affected person, this data can not be perceived or verified by another person
Interview is a planned communication
Validation is the act of confirming or verifying
Cue significant data that is helpful in making decisions
Inference the judgement reached about a cue
Health problem is a condition that necessitates intervention to prevent or resolve desease or illness or to promote coping and wellness
Nursing diagnoses Actual or potential health problems that can be prevented or resolved by independent nursing interventions (focuses on unhealthy respones to healtha and illness)
Medical diagnoses identifies the disease
Collaborative problems certain physiologic complications that nurses monitor to detect onset or changes in status
Diagnostic error failure to detect an actual unhealthy behavior
Data cluster is grouping pt data or cues that points to the existence of a pts health problem
Standard or a norm, is a generally accepted rule, measure, pattern. or model to which data can be compared in the same class or category
Created by: jessinms