Steven Shared "2015 NCLEX Fundamentals - Physical Exam" - 23 Picmonics
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2015 NCLEX Fundamentals - Physical Exam
Vital Signs - Adult
- Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
- Rectal
- Tympanic
- Oral
- Axillary
- Temporal
- Respiration (12-20)
- Oxygen Saturation (94%-100%)
- Pulse (60-100)
- Blood Pressure (<120/80)
- Pain
2 mins
Neurovascular Assessment 6 P's
- Pain
- Paresthesia
- Pulse
- Pallor
- Pressure
- Paralysis
1 min
Pain Assessment
- Types of Pain
- Acute Pain
- Chronic Pain
- OPQRST Mnemonic
- Onset
- Provoking or Palliative
- Quality
- Radiation
- Severity
- Timing
- Nursing Considerations
- Subjective Findings
- Objective Findings
- Reassessment of Pain
2 mins
Prevention of Falls
- Risk Factors
- Physical Aging
- Polypharmacy
- Environmental
- Hospital / Facility Prevention
- Call Light within Reach
- Assistive Devices Available
- Bed Alarms
- Home Prevention
- Improve Lighting
- Remove Home Hazards
- Priority Nursing Interventions
- Promote Exercise
- Fall Risk Assessment
2 mins
Immobility
- Assessment
- Mobility Continuum
- Complications
- Cardiovascular
- Respiratory
- Musculoskeletal
- Integumentary
- Gastrointestinal
- Urinary
- Considerations
- Turn, Cough, Deep Breathe (TCDB)
- Range of Motion (ROM)
- Skin Care
- Fluids
- Balanced Diet
2 mins
Sizing Crutches
- 3 Finger Widths
- 6 Inches Lateral From Heel
- 30 Degree Flexion
- Tripod Position
1 min
Cane
- COAL
- Sizing a Cane
- Quad Cane
- Rubber Tips for Safety
1 min
Walker
- Walker with Affected Leg
- Sizing a Walker
- Rubber Tips for Safety
55 secs
Diet Progression
- Types of Diets
- Clear Liquid
- Full Liquid
- Pureed
- Mechanical Soft
- Low Residue (Fiber)
- High Fiber
- Regular
1 min
Therapeutic Diets
- Common Therapeutic Diets
- High Fiber
- Low Residue (Fiber)
- Low Sodium
- Low Cholesterol
- Diabetic
- Renal
- Dysphagia
- Nursing Considerations
- Diet Education
2 mins
Fever
- Flushed skin, warm to touch
- Chills
- Sweating
- Change in LOC
- Provide adequate fluids
- Monitor Electrolytes and Fluid
- Monitor vital signs, esp temperature
- Remove excess clothing and blankets
- Sponge bath with tepid water
2 mins
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
- Conscious
- Confused
- Delirious
- Somnolent
- Obtunded
- Stuporous
- Comatose
3 mins
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
1 min
Fire - Environmental Emergencies
- R.A.C.E
- Rescue
- Alarm
- Confine
- Extinguish
- P.A.S.S.
- Nursing Considerations
- Fire Exits
- Do Not Use Elevators
- Manual Ventilation
2 mins
Tuberculosis Skin Mantoux Test (PPD)
- Delayed Hypersensitivity (Cell Mediated Response)
- Intradermal Injection
- Read 48-72 hours
- Positive Results
- ≥ 5 mm Induration
- Immunosuppressed
- ≥ 10 mm Induration
- High Risk Patients
- ≥ 15 mm Induration
- Considerations
- Chest X-Ray
3 mins
Magnetic Resonance Imaging (MRI)
- Procedure
- Internal Body Images
- Detects Variations of Soft Tissues
- Considerations
- No Metal Objects
- No Pacemakers
- Contrast is Non-Iodine
- Safe During Pregnancy
- Long Procedure
- Antianxiety Medications
2 mins
Total Parenteral Nutrition (TPN)
- Mechanism
- Nutrition Given Outside GI
- Side Effects
- Hyperglycemia
- Hyperlipidemia
- Refeeding Syndrome
- Nausea and Vomiting
- Considerations
- Slow IV Infusion
- Use Large Central Vein
- No Added Meds to TPN Line
2 mins
Cobalamin (Vitamin B12)
- Mechanism
- Vitamin B12
- Indications
- Vitamin Deficiency
- Pernicious Anemia
- Side Effects
- Hypokalemia
- Arthralgia
- Dizziness
- Considerations
- IM Injection for Pernicious Anemia
- Never Give IV
2 mins
Iron (Ferrous Sulfate)
- Mechanism
- Ferrous Salts
- Indications
- Anemia
- Side Effects
- GI Distress
- Nausea and Vomiting
- Dark Stools
- Considerations
- Take Between Meals
- Liquid can Stain Teeth
- Keep out of Reach from Children
- Caution with GI Disorders
- Avoid Antacids
3 mins
Vitamin K1 (Phytonadione)
- Mechanism
- Synthesizes Clotting Factors II, VII, IX, X
- Indications
- Hypoprothrombinemia
- Newborn Prophylaxis
- Bleeding from Warfarin Overdose
- Side Effects
- Shock
- Kernicterus
- Cardiac Arrest
- Considerations
- Bile Salts required for Intestinal Absorption
- Increased Risks with IV Administration
2 mins
