Fundamentals
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| Inspection | is the process of performing deliberate, purposful observations in a systemic manner.
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| Palpation | is an asssessment technique that uses the sense of touch. The hands/fingers can asses temperature, turgor, texture, moisture, vibrations, and shape.
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| The dorsum (Back) of the had is used for | gross measure of temperature.
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| 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
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| Percussion | is the act of striking one object against another to produce sound. Used to assess the location, shape, size, and density of tussues.
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| Ausculation | is the act of listening with a stethoscope to sounds produced within the body.
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| Erythema | Redness of the skin. Most often seen in face and neck
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| Cyanosis | is a bluish or grayish discoloration of the skin in response to inadequate oxgyenation
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| 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.
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| Pallor | paleness of th skin, often from inadequate amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues.
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| Ecchymosis | is a collection of blood in the subctaneous tissues, causing purplish discoloration.
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| Petechiae | are small hemorrhagic spots caused by capillary bleeding. If present asses location, color, and size
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| 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.
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| Edema | ixcess fluid in the tissues. Swelling taut and shiny skin over the edematous area.
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| Pitting edema | when the area of the edema is palpated with the fingers, an indentatin may remain after the pressure is relased.
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| Bronchial sounds | are heard over the trachea are high pitched, harsh sounds, with expiration being longer than inspiration
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| Bronchovesicular sounds | are heard over the mainstem bronchus and are moderate "blowing" sounds with inspiration equal to expiration
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| Vesicular breath sounds | are soft, low pitched sounds, heard best over the base of the lungs during inspiration, which is longer than expiration
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| Adventitious breath sounds | are not normally heard in the lungs but, if present may be ausculated along with normal breath sounds
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| 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.
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| 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
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| 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.
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| Assessing | systematically collect pt data
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| Diagnosing | Clearly identify pt strengths and actual and potential problems
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| 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
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| Implementing | Execute the plan of care
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| Evaluating | Evaluating the effectiveness of the plan of care in terms of pt goal achievment
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| 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
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| 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.
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| Intutive thinking | flashes of intuition
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| 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.
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| Critical thinking | a systematic way to form and shape one's thinking, It is disciplined, comprehensive, based on intellectual standards, and well reasoned.
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| Technically skilled | nurse that is able to manipulate equipment skillfully to produce a desired outcome or result.
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| 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.
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| Ethically and legally skilled | a nurse that can conduct themselves in a manner consistent with their personal moral code and professional role responsibilities
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| Standards for critical thinking | clear, precise, specific, acurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair.
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| 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.
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| Assessing | is the systemic and continous collection, validation, and communication of pt data
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| Data | information
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| Database | all the pertinent information that enables a comprehensive and effective plan of care to be designed and implemented for the pt
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| Initial assessment | is performed shortly after the pt is admitted to a healthcare agency or service
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| Focused assessment | the nurse gathers data about a specific problem that has already been identified.
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| Emergency assessment | To identify lifethreatening problems
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| Time-lasped assessment | is scheduled to compare a pt current status to baseline datat obtained earlier
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| 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
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| Objective data | observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
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| Subjective data | is information pereceived only by the affected person, this data can not be perceived or verified by another person
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| Interview | is a planned communication
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| Validation | is the act of confirming or verifying
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| Cue | significant data that is helpful in making decisions
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| Inference | the judgement reached about a cue
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| Health problem | is a condition that necessitates intervention to prevent or resolve desease or illness or to promote coping and wellness
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| 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)
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| Medical diagnoses | identifies the disease
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| Collaborative problems | certain physiologic complications that nurses monitor to detect onset or changes in status
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| Diagnostic error | failure to detect an actual unhealthy behavior
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| Data cluster | is grouping pt data or cues that points to the existence of a pts health problem
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| 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
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