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 - Remove 1 Degree
Axillary - Add 1 Degree
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
59 secs
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
54 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 with Food
Liquid can Stain Teeth
Keep out of Reach from Children
Caution with GI Disorders
Avoid Antacids
2 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

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