Kaitlin Shared "N125 Assessment basics" - 25 Picmonics

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N125 Assessment basics

Reports
Reporting
Shared Communication
ISBAR
ISBAR
Identify
Situation
Background
Assessment
Recommendation
Types of Reports
Change-of-Shift/Handoff Reports
Telephone/Telemedicine Reports
Transfer and Discharge Reports
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2 mins
Registered Nurse Roles
Nursing Roles in All Settings
Caregiver
Counselor
Educator/Teacher
Communicator
Advocate
Leader
Researcher
Collaborator
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2 mins
Assessment
Health History
Objective Data
Subjective Data
TEST-TAKING STRATEGY: KEY WORDS
Identify
Determine
Obtain Information
CONSIDERATIONS
Assessment Always Done Before Treatments
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3 mins
Implementation
Types of Nursing Interventions
Direct Care Interventions
Indirect Care Interventions
A Community (Public Health) Intervention
Implementing the Care Plan
Partnership with the Patient/Family
Performing the Nursing Action
Documenting Nursing Care
Delegating Nursing Care
TEST-TAKING STRATEGY: KEY WORDS
Intervene
Priority Action
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3 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
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2 mins
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
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2 mins
I-SBAR-R
Identify
Situation
Background
Assessment
Recommendation
Readback
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1 min
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
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1 min
6 Rights of Medication Administration
Right Patient
Right Medication
Right Dose
Right Time
Right Route
Right Documentation
Nursing Considerations
Three Checks
Check for Allergies
Assess the Patient
Education
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2 mins
Diagnosis
A COMPARISON
Medical Diagnosis
Nursing Diagnosis
Collaborative Problem
Data Interpretation and Analysis
Significant Data
Patterns or Clusters
Parts of Nursing Diagnosis Statement
Problem
Etiology
Defining Characteristics
TEST-TAKING STRATEGY: KEY WORDS
Maslow’s Pyramid
Patient’s Concerns
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2 mins
Planning
Nursing Care Plan
Tailored to Patient
Short-and-Long-Term Goals
SMART GOALS
Specific
Measurable
Attainable
Realistic
Time-Oriented
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2 mins
Evaluation
Consider the Effectiveness of Care
Reassess
Make Necessary Modifications
Continuously Ensure Favorable Patient Outcome
TEST-TAKING STRATEGY: KEY WORDS
Evaluate
Outcome
Consider the Degree of Effectiveness
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2 mins
Intramuscular Medication (IM) Administration
Risks
Injury to Nerves, Bone, and Blood Vessels
Sites
Deltoid
Vastus Lateralis
Ventrogluteal
Nursing Considerations
Selection of Needle Length
Aseptic Technique for Drawing Up
Z-Track
90 Degree Angle
Max Amount (2-5 mL Adult, 1 mL Child)
Techniques to Reduce Pain
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2 mins
Transdermal Medication Administration
Application
Patch or Disc
Directly on Skin of Arms, Chest, Upper Back
Benefits
Avoids First Pass Metabolism
Sustained Administration of Medication
Nursing Considerations
Clean Skin After Removal
Rotate Sites of Patches
Apply to Dry Skin
Avoid Shaved Skin
Avoid Heat
Nitro Effects Lost After 24 Hours
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2 mins
Ear Drops Medication Administration
Indications
Earwax Buildup
Ear Infections
Pulling The Pinna
Child - Back and Downward
Adult - Back and Upward
Procedure
Side-Lying with Ear Up
Instill Medication
Stay for 2-3 Minutes
Nursing Considerations
Room Temperature
May Massage Tragus
Perforated Eardrum
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2 mins
Eye Medication Administration
Procedure
Supine with Neck Hyperextended
Wash Away Crusts
Cotton Ball on Cheekbone
For Ophthalmic Drops
Instill Drops into Conjunctival Sac
Repeat if Missed or Patient Blinks
5 Minutes Before 2nd Medication
For Ophthalmic Ointment
Thin Stream Along Inner Edge
Inner Canthus to Outer Canthus
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2 mins
Routes of Administration Part One
Enteral Administration
Oral
Sublingual
Buccal
Rectal
Tubes
Topical or Mucous Membrane Administration
Transdermal
Drops/Spray
Vaginal
Inhalation Administration
Inhalation
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2 mins
Routes of Administration Part Two (Parenteral)
Parenteral Administration
Intradermal
Subcutaneous
Intramuscular (IM)
Intravenous
Epidural
Intrathecal
Intraosseous
Intraperitoneal
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2 mins
Braden Scale
Characteristics
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
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2 mins
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
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1 min

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