week 1 Flashcards
What types of quality improvement are there at an agency level?
Quality and performance
What is the focus of quality improvement evaluation?
The delivery of care provided by an agency or a specific nursing division within that agency
what is inspection?
it is concentrated watching
close and careful scrutiny
bilateral comparison
what is palpation?
the use of the sense of touch to examine
what are the characteristics assessed by palpation?
texture temperature moisture organ location & size swelling vibration or pulsation rigidity or spasticity crepitation presence of lumps or masses presence of tenderness or pain
why are the dorsa of the hands and fingers best for determining temperature?
the skin on the backs of the hands are thinner than the palms and thus better for taking temperature
what are the base of the fingers (metacarpophalangeal joints) best for assessing?
vibration
what is a grasping action of the fingers and thumb good at palpating?
the consistency, shape, and position of an organ or mass
what are the fingertips used to palpate?
best for fine tactile discrimination like skin, texture, swelling, pulsation, and determining presence of lumps
what is percussion?
the tapping of skin with short, sharp strokes to assess underlying structures
yields palpable vibration and characteristic sounds that reveal location, size, density of underlying organ
what is direct percussion?
striking hand contacts body wall directly
what is indirect percussion?
there is a stationary hand and a striking hand. the striking hand strikes the stationary hand
what are the characteristics of percussion notes?
resonant hyperresonant tympany dull flat
what are the variations in percussion notes?
amplitude
pitch
quality
duration
What is auscultation?
the use of the sense of hearing for sounds produced by the hear, blood vessels, lungs, and abdomen channeled through a stethoscope
how does a stethoscope aid in auscultation?
it eliminates confusing artifacts by isolating sounds
What is an otoscope?
it is a device that funnels light into the ear canal and onto the tympanic membrane
What is an opthalmoscope?
a device that illuminates the internal eye structures
allows visualization through the pupil to the fundus of the eye
what does it mean to have a “clean field”?
//all equipment carried from patient to patient, notably your stethoscope, must be cleaned with alcohol between patients //there should be a clean and dirty area for handling equipment used in the physical examination
what are the steps of the nursing process?
nursing assessment nursing diagnosis planning nursing care implementing nursing care evaluating nursing care
what are the elements of the assessment portion of the nursing process?
- subjective data
2. objective data
what are the elements of the diagnosis portion of the nursing process?
- data analysis
- problem identification
- label
what are the elements of the planning portion of the nursing process?
- priorities
- goals
- interventions
what are the elements of the implementation portion of the nursing process?
- nurse-initiated treatments
2. physician-initiated treatments
what are the components of the evaluation portion of the nursing process?
- data
- diagnosis
- etiologies
- plans
- interventions
why do nurses do data collection as part of the examination?
//to establish a database of client's perceived needs, health problems, and responses //uncovers experiences, health practices, goals, values, and expectations
What are the two types of data?
//subjective (client's own words) //objective (observations of clinical measurements or assessments)
What kind of data collection is history taking?
subjective - it is what the patient says
what kind of data collection is the physical examination?
objective data - what the health care provider observes
what are the components of the physical examination?
//observation of client behaviour
//diagnostic and laboratory data
//interpreting assessment data and making nursing judgments: data validation and analysis & interpretation
what is the last component of assessment?
Documentation!
what kinds of things should be documented?
anything heard, seen, felt, or smelled should be reported accurately
//subjective client information should be placed in quotation marks
what is the definition of a medical diagnosis?
a clinical judgments about the client in response to an actual or potential health problem
what is the definition of a nursing diagnosis?
the identification of a disease condition based on specific evaluation of signs and symptoms
what is the definition of a collaborative problem?
an actual or potential complication that nurses monitor to detect a change in client status
what is an actual nursing diagnosis?
it describes human responses to levels of wellness that have a readiness for enhancement
what is a risk nursing diagnosis?
it describes human responses to health conditions or life processes that may develop
what is a health-promotion nursing diagnosis?
it is a clinical judgement of motivation and desire to increase well-being by readiness to enhance specific health behaviours, such as nutrition and exercise
what is a wellness nursing diagnosis?
it describes human responses to health conditions or life processes
what are the components of a nursing diagnosis?
//diagnostic label //related factors //definition //risk factors //support of the diagnostic statement
what are the classifications of priorities?
high
intermediate
low
why is establishing priorities valuables?
it helps nurses to anticipate and sequence nursing interventions
what are three phases of the planning of nursing care?
//initial //ongoing //discharge
what is a goal?
a broad statement that describes the desired change in a client’s condition or behaviour
it is an aim, intent or end
what is an expected outcome?
a measurable criteria to evaluate goal achievement
specific, measurable changes in a client’s status
they provide focus or direction
determine when a specific client-centered goal has been met
what kinds of goals are there to care?
//client goals
//short-term goals
//long-term goals
what is a client goal?
it is a specific, measurable behaviour or response reflecting client’s highest possible wellness level and independence of function
what is a short-term goal?
it is an objective client behaviour or response expected within hours to a week
what is a long-term goal?
it is an objective client behaviour or response expected within days, weeks, or months
what seven things should a goal be?
- client-centered
- singular
- observable
- measurable
- time-limited
- mutual
- realistic
What are the types of interventions?
nurse-initiated - independent
physician-initiated - dependent
collaborative - interdependent
how is critical thinking used during implementation?
//review the sets of all possible nursing interventions
//review all possible consequences associated with each possible nursing action
//determine the probability of all possible consequences
//determine the effect of the intervention
what is involved in the implementation process?
//reassessing the client //reviewing and revising the existing nursing care plan //organizing resources and care delivery //anticipating and preventing complcations
what are the three types of skills important for the implementation portion of the nursing process?
//cognitive skills //interpersonal skills //psychomotor skills
what are forms of direct care?
//activities of daily living //instrumental activities of daily living //physical care techniques //lifesaving measures //counselling //teaching //controlling for adverse reactions //preventive measures
what are forms of indirect care?
//communicating nursing interventions - written or oral //delegating, supervising, and evaluating the work of other health care team members
what are the five elements of the evaluation process?
- identify evaluative criteria and standards
- collect evaluative data
- interpret and summarize
- document findings and clinical judgments
- terminate, continue, or revise the care plan
what are results of evaluation?
care plan revision
discontinuing a care plan
modifying a care plan
What is the difference between direct and indirect nursing interventions.
Direct nursing interventions are interactions with patients
Indirect nursing interventions are tasks like safety and infection prevention that are for the patients benefit, but don’t directly involve the patient at all
