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Key terms U-2
Fundamentals
| Term | Description |
|---|---|
| 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
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