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fundamentals
Vital Signs - Adult
Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
Rectal
Tympanic
Oral
Axillary
Temporal
Respiration (12-20)
Oxygen Saturation (95%-100%)
Pulse (60-100)
Blood Pressure (<120/80)
Pain
2 mins
Neurovascular Assessment 6 P's
Pain
Paresthesia
Pulse
Pallor
Pressure
Paralysis
1 min
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
1 min
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
3 mins
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
Child and Elder Physical Abuse Assessment
Physical Abuse
Inconsistent Injuries
Delay in Treatment
Various Stages of Healing
Child Abuse
Symmetrical Burns
Sexually Transmitted Infection
Bloody/Torn Undergarments
Shaken Baby Syndrome
Elder Abuse
Poor Hygiene
Overmedication
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
The Nursing Process
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
2 mins
Maslow's Hierarchy of Needs
Physiological Needs
Oxygen, Water, Nutrition
Body temperature, Elimination, Shelter, Sexual Expression
Safety and Security
Physical Safety
Physiological Safety
Love and Belonging
Affection and Companionship
Esteem
Self Respect and Respect for Others
Self Actualization
Fulfillment
2 mins
Patient Position Overview
Position Techniques
Trochanter Roll
Trapeze Bar
Ankle-Foot Orthotic (AFO) Devices
Positions
Fowlers Position
Supine Position
Trendelenburg
Side-Lying Position
Prone Position
Sims' Position
Nursing Considerations
Reposition q2 Hours/Prevent Skin Breakdown
Confirm Body Alignment
2 mins
Care for the Visually Impaired
Assessment
Decreased Visual Acuity
Snellen Chart
Status of Corrective Lenses
Nursing Considerations
Sighted-Guide Technique
Communication
Safe Environment
Medications
Clock Technique for Food
Activities of Daily Living (ADL)
1 min
Care for the Hard of Hearing
Assessment
Normal: 0-15 dB
Rinne's Test
Weber's Test
Tinnitus
Difficulty Following Conversations
Nursing Considerations
Face Patient/Speak Clearly
Rephrase Misunderstood Statements
Repeat Statements Back
Hearing Aids
Sign Language
2 mins
I-SBAR-R
Identify
Situation
Background
Assessment
Recommendation
Readback
1 min
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
1 min
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
Seizure Precautions
Reduce Environmental Stimuli
Identify Triggers
Aura
Pad Side Rails
Bed Lowest Position
Oxygen and Suction Available
Consideration
Monitor Therapeutic Drug Levels
2 mins
Seizure Interventions
Maintain Airway
Side-lying Position
Support Head
Move to Floor
Benzodiazepines
Considerations
Never Restrain
No Objects in Mouth
Document Details
2 mins
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
Bleeding Precautions
Things to Avoid
Hard Foods
Aspirin Products
Blowing Nose Forcefully
Straining During BMs
Enemas or Rectal Suppositories
Pads and Monitor Menstruation
Guidelines to Follow
Soft-bristled Toothbrush
Electric Razor
Limit Needle Sticks
Smaller Needle Size
3 mins
Use of Restraints
Use Guidelines
During Emergency
Protecting From Harm
For Limited Time
Considerations
Last Resort
May Further Agitation
Frequent Observation
Obtain Order Within 1 Hour
Quick-Release Tie
2 mins
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