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Teresa Shared "NUR 216" - 23 Picmonics

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NUR 216

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
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
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2 mins
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
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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
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2 mins
Standard Precautions
Hand Hygiene
Wash In / Wash Out
Alcohol-Based Hand Rub
Hand Washing
Personal Protective Equipment (PPE)
Gown
Face Mask
Goggles/Face Shield
Gloves
Donning and Removing PPE
Discard Sharps in Puncture-Resistant Container
Cough Etiquette
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2 mins
Religion and Dietary Preferences Overview
Buddhism
Natural Foods of Earth
Hinduism
Cow is Sacred
Islam (Muslim)
Halal Foods
No Alcohol
Judaism
Kosher Meals
No Pork or Shellfish
Mormonism (Latter Day Saints)
The Word of Wisdom
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1 min
Eye
Characteristics
Sclera
Cornea
Iris
Lens
Ciliary Muscles
Optic Nerve
Rods
Cones
Retina
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1 min
Otitis Media Assessment
Red or Bulging Tympanic Membrane
Ear Pain
Pulling at Ear
Fever
Upper Respiratory Infection
Considerations
More Common in Young Children
Eustachian Tube Narrower
Conductive Hearing Loss
Smoking Increases Risk
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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
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
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3 mins
Cranial Nerve Function
Sensory
CN I
CN II
CN VIII
Motor
CN III
CN IV
CN VI
CN XI
CN XII
Both
CN V
CN VII
CN IX
CN X
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1 min
CN I
Olfactory Nerve
Sensory
Smell
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36 secs
CN II
Optic Nerve
Sensory
Vision
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35 secs
CN III
Oculomotor Nerve
Motor
Eye Movement
Accommodation
Eyelid Opening
Pupillary Constriction
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1 min
CN IV
Trochlear Nerve
Motor
Abducts, Depresses, Internally Rotates
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48 secs
CN V
Trigeminal Nerve
Sensory
Facial Sensation
Motor Function (Via Mandibular Nerve)
Mastication Muscles
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1 min
CN VI
Abducens Nerve
Motor
Abducts Eye
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48 secs
CN VII
Facial Nerve
Lacrimation
Salivation
Sensory
Taste from Anterior 2/3 of Tongue
Motor
Facial Movement
Stapedius Muscle
Eyelid Closing
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1 min
CN VIII
Vestibulocochlear Nerve
Sensory
Hearing
Balance
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55 secs
CN IX
Glossopharyngeal Nerve
Sensory
Taste from Posterior 1/3 of Tongue
Monitoring Carotid Body and Sinus
Motor
Stylopharyngeus
Swallowing
Salivation
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1 min

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