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NURS 203 > week 1 > Flashcards

week 1 Flashcards

1
Q

What types of quality improvement are there at an agency level?

A

Quality and performance

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2
Q

What is the focus of quality improvement evaluation?

A

The delivery of care provided by an agency or a specific nursing division within that agency

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3
Q

what is inspection?

A

it is concentrated watching

close and careful scrutiny

bilateral comparison

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4
Q

what is palpation?

A

the use of the sense of touch to examine

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5
Q

what are the characteristics assessed by palpation?

A 
texture
temperature
moisture
organ location & size
swelling
vibration or pulsation
rigidity or spasticity
crepitation
presence of lumps or masses
presence of tenderness or pain
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6
Q

why are the dorsa of the hands and fingers best for determining temperature?

A

the skin on the backs of the hands are thinner than the palms and thus better for taking temperature

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7
Q

what are the base of the fingers (metacarpophalangeal joints) best for assessing?

A

vibration

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8
Q

what is a grasping action of the fingers and thumb good at palpating?

A

the consistency, shape, and position of an organ or mass

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9
Q

what are the fingertips used to palpate?

A

best for fine tactile discrimination like skin, texture, swelling, pulsation, and determining presence of lumps

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10
Q

what is percussion?

A

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

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11
Q

what is direct percussion?

A

striking hand contacts body wall directly

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12
Q

what is indirect percussion?

A

there is a stationary hand and a striking hand. the striking hand strikes the stationary hand

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13
Q

what are the characteristics of percussion notes?

A 
resonant
hyperresonant
tympany
dull
flat
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14
Q

what are the variations in percussion notes?

A

amplitude
pitch
quality
duration

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15
Q

What is auscultation?

A

the use of the sense of hearing for sounds produced by the hear, blood vessels, lungs, and abdomen channeled through a stethoscope

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16
Q

how does a stethoscope aid in auscultation?

A

it eliminates confusing artifacts by isolating sounds

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17
Q

What is an otoscope?

A

it is a device that funnels light into the ear canal and onto the tympanic membrane

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18
Q

What is an opthalmoscope?

A

a device that illuminates the internal eye structures

allows visualization through the pupil to the fundus of the eye

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19
Q

what does it mean to have a “clean field”?

A 
//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
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20
Q

what are the steps of the nursing process?

A 
nursing assessment
nursing diagnosis
planning nursing care
implementing nursing care
evaluating nursing care
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21
Q

what are the elements of the assessment portion of the nursing process?

A
  1. subjective data

2. objective data

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22
Q

what are the elements of the diagnosis portion of the nursing process?

A
  1. data analysis
  2. problem identification
  3. label
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23
Q

what are the elements of the planning portion of the nursing process?

A
  1. priorities
  2. goals
  3. interventions
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24
Q

what are the elements of the implementation portion of the nursing process?

A
  1. nurse-initiated treatments

2. physician-initiated treatments

25
Q

what are the components of the evaluation portion of the nursing process?

A
  1. data
  2. diagnosis
  3. etiologies
  4. plans
  5. interventions
26
Q

why do nurses do data collection as part of the examination?

A 
//to establish a database of client's perceived needs, health problems, and responses
//uncovers experiences, health practices, goals, values, and expectations
27
Q

What are the two types of data?

A 
//subjective (client's own words)
//objective (observations of clinical measurements or assessments)
28
Q

What kind of data collection is history taking?

A

subjective - it is what the patient says

29
Q

what kind of data collection is the physical examination?

A

objective data - what the health care provider observes

30
Q

what are the components of the physical examination?

A

//observation of client behaviour

//diagnostic and laboratory data

//interpreting assessment data and making nursing judgments: data validation and analysis & interpretation

31
Q

what is the last component of assessment?

A

Documentation!

32
Q

what kinds of things should be documented?

A

anything heard, seen, felt, or smelled should be reported accurately

//subjective client information should be placed in quotation marks

33
Q

what is the definition of a medical diagnosis?

A

a clinical judgments about the client in response to an actual or potential health problem

34
Q

what is the definition of a nursing diagnosis?

A

the identification of a disease condition based on specific evaluation of signs and symptoms

35
Q

what is the definition of a collaborative problem?

A

an actual or potential complication that nurses monitor to detect a change in client status

36
Q

what is an actual nursing diagnosis?

A

it describes human responses to levels of wellness that have a readiness for enhancement

37
Q

what is a risk nursing diagnosis?

A

it describes human responses to health conditions or life processes that may develop

38
Q

what is a health-promotion nursing diagnosis?

A

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

39
Q

what is a wellness nursing diagnosis?

A

it describes human responses to health conditions or life processes

40
Q

what are the components of a nursing diagnosis?

A 
//diagnostic label
//related factors
//definition
//risk factors
//support of the diagnostic statement
41
Q

what are the classifications of priorities?

A

high
intermediate
low

42
Q

why is establishing priorities valuables?

A

it helps nurses to anticipate and sequence nursing interventions

43
Q

what are three phases of the planning of nursing care?

A 
//initial
//ongoing
//discharge
44
Q

what is a goal?

A

a broad statement that describes the desired change in a client’s condition or behaviour

it is an aim, intent or end

45
Q

what is an expected outcome?

A

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

46
Q

what kinds of goals are there to care?

A

//client goals

//short-term goals

//long-term goals

47
Q

what is a client goal?

A

it is a specific, measurable behaviour or response reflecting client’s highest possible wellness level and independence of function

48
Q

what is a short-term goal?

A

it is an objective client behaviour or response expected within hours to a week

49
Q

what is a long-term goal?

A

it is an objective client behaviour or response expected within days, weeks, or months

50
Q

what seven things should a goal be?

A
  1. client-centered
  2. singular
  3. observable
  4. measurable
  5. time-limited
  6. mutual
  7. realistic
51
Q

What are the types of interventions?

A

nurse-initiated - independent
physician-initiated - dependent
collaborative - interdependent

52
Q

how is critical thinking used during implementation?

A

//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

53
Q

what is involved in the implementation process?

A 
//reassessing the client
//reviewing and revising the existing nursing care plan
//organizing resources and care delivery
//anticipating and preventing complcations
54
Q

what are the three types of skills important for the implementation portion of the nursing process?

A 
//cognitive skills
//interpersonal skills
//psychomotor skills
55
Q

what are forms of direct care?

A 
//activities of daily living
//instrumental activities of daily living
//physical care techniques
//lifesaving measures
//counselling
//teaching
//controlling for adverse reactions
//preventive measures
56
Q

what are forms of indirect care?

A 
//communicating nursing interventions - written or oral
//delegating, supervising, and evaluating the work of other health care team members
57
Q

what are the five elements of the evaluation process?

A
  1. identify evaluative criteria and standards
  2. collect evaluative data
  3. interpret and summarize
  4. document findings and clinical judgments
  5. terminate, continue, or revise the care plan
58
Q

what are results of evaluation?

A

care plan revision
discontinuing a care plan
modifying a care plan

59
Q

What is the difference between direct and indirect nursing interventions.

A

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

NURS 203 (6 decks)

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