Module 2 Flashcards
Vital Signs
Describe the components of a general survey.
1) Physical appearance: skin colour/ condition, age, facial expression, body build.
2) Body Structure: assess posture, gait, body movements.
3) Mobility: posture, gait, range of motion
4) Behaviour: hygiene, dress, eye contact, body language, anxiety, pain/comfort/distress, age related considerations
5) Mental status: mood/ affect, speech, orientation x3 (person, place, and time)
Explain the nursing process and list the nursing process
-Cognitive framework through which one aims to identify,diagnose, and treat actual and potential health issues and challenges from a holistic perspective
Nursing process includes: Assessment, analysis, planning, implementation, evaluation
Describe different types of health assessment
IAPP: Inspect, auscultate, palpate, percuss.
Define inspection, palpation, percussion, auscultation
1) Inspection: use of vision and hearing to tell normal from abnormal findings. Inspect each area for size, shape, colour, symmetry, position, drainage, and abnormalities.
2) Palpation: use of the hand to touch the body to make sensitive assessments. Light intermittent pressure is best.
3) Percussion: tapping the body with the fingertips to produce a vibration that travels through the body tissues.
4) Auscultation: listening to the sounds the body makes to detect variations from normal, most require a stethoscope. Blowing or gurgling describe the quality of sound.
Describe critical thinking, clinical decision making and how these are used in implementing the nursing process
- Critical thinking: Interpretation (look for patterns, what is the info telling me?), Analysis (ask why data may be true?, don’t make assumptions), Inference (examine meaning of data, form hypothesis and conclusion), Evaluation (determine effectiveness of nursing action), Explanation (use knowledge or experience to select strategies for nursing care), Self-regulation (reflect on experiences, stick to nursing standards).
- Clinical decision making: Clinical judgement has 4 parts: noticing the situation, developing a sufficient understanding of the situation to respond, deciding on a course of action, reviewing the actions taken and their outcomes.
- When using the nursing process, you identify a patients’ health related concern, clearly define a nursing diagnosis or collaborative problem, determine priorities of care, set goals and have expected outcomes of care.
Differentiate between objective & subjective data gathering
Subjective Data: only clients provide subjective data. Usually includes feelings, perceptions, and self report of symptoms.
Objective Data: observations or measurements of a clients’ health status. Based on an accepted standard or known characteristics of behaviour.
Describe principles that guide prioritization of nursing care
Low Priority: not always directly related to a specific illness/ prognosis but may affect clients future well being.
Medium priority: non-emergency, non life threatening needs of the client.
High priority: conditions that left untreated would result in harm to the client, sometimes both psychological/ physiological.
How is the ‘assessment’ of the nursing process used in nursing practice?
- collection of pertinent data to the clients’ health status or situation
- Areas of strengths and concerns. To determine the patients past and current health and functional status and to determine the client’s present and past coping patterns.
- The assessment establishes an individualized data-base about the clients health status to include his or her perceived needs, health challenges, and problems and to respond to them.
How is the ‘analysis’ of the nursing process used in nursing practice?
- Nurses would begin by organizing the information gathered into different clusters (set of signs or symptoms grouped in a logical way).
- During data clustering, the nurse will organize data and focus attention on client functions to determine which support or assistance is needed for recovery.
How is ‘planning’ of the nursing process used in nursing practice?
- Identify goals, plan one at a time. Quantifiable
- differentiate between low (not always directly related to client’s current issues. Long term care needs) , medium (non-emergency and non-life threatening), high priority (critical needs that need to be worked on immediately, life-threatening)
- Setting the goal shows proof of progress toward a resolution, improved health status, or continued maintenance of optimal health.
Describe the two ways nurses can implement nursing care (Direct and indirect nursing intervention)
Direct: treatments performed through interactions with clients.
Indirect: treatments performed away from the client but on behalf of the client. Includes managing the environment, ie safety and infection control. E.g documentation and interdisciplinary collaboration
Describe the three types of implementation skills used by nurses: cognitive, interpersonal, and psychomotor
Cognitive: using critical thinking skills to think and anticipate to individualize care for clients and ensure their safety
- Interpersonal: to develop a trusting relationship, express a caring attitude, and have clear communication.
- Psychomotor: integration of cognitive and motor skills. E.g. when giving an injection, nurses must use cognitive (understanding anatomy, physiology, and pharmacology), as well as motor skills (coordination and precision)
How can you revise the nursing care plan?
- Reassess patient: (nurse interacts with a client to modify the plan of care as the clients needs change or are resolved)
- Reviewing and revising the existing care plan: compare assessment data to validate nursing diagnosis, and determine if current interventions remain to be the most appropriate.
1. Revise data in the assessment column to reflect current status, date new data
2. Revise nursing diagnosis. Delete non relevant diagnoses, add/ date new ones
3. Revise specific interventions corresponding to new nursing diagnosis/ goal
4. Determine method of evaluation for any outcomes achieved.
What are some examples of direct nursing intervention?
Activities of daily living (ADLs): assisting with everyday activities such as eating, ambulation
Instrumental activities of daily living (IADLs): assisting with daily activities such as shopping, meal prep. More common in home care/ community care settings.
Physical care techniques: turning and positioning, changing dressings, administering medications, and providing comfort measures.
Life saving measure: Includes administering emergency meds, CPR, intervening to protect a confused/ violent patient, and providing a safe environment during a mental health crisis.
Counselling: engaging in emotional, intellectual, spiritual, and psychological support for the client.
Teaching: helping clients to learn about their health status, ways of promoting health, and caring for themselves.
Controlling for adverse reactions: reading or counteracting the adverse effects of a medication, diagnostic test, or therapeutic intervention. Monitoring the effects of an intervention and evaluating for expected outcomes.
Preventive measures: promoting health and preventing illness through assessment and promotion of the clients health potential, carrying out prescribed measures (immunizations), health teaching, identifying risk factors for illness/ trauma/ both
What are some examples of indirect nursing intervention?
Communicating: client interventions will be communicated in a written or oral format. Written interventions are part of the nursing care plan and permanent medical record.
Delegating, supervising, evaluating others’ work: not all nursing interventions will be carried out by the nurse who assigns them, so when delegating you must ensure that each task is appropriately assigned and completed.
