Luz Shared "assessment" - 85 Picmonics

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assessment

Neurovascular Assessment 6 P's
Pain
Paresthesia
Pulse
Pallor
Pressure
Paralysis
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1 min
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
Conscious
Confused
Confused
Delirious
Delirious
Somnolent
Somnolent
Obtunded
Obtunded
Stuporous
Stuporous
Comatose
Comatose
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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
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
The Nursing Process
ADPIE
Assessment
Diagnosis
Planning 
Realistic
Individualized to the Patient
Timed
Implementation
Evaluation
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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
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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
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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
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
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)
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1 min
Care for the Hearing Impaired
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
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2 mins
R.I.C.E. (Treating Soft Tissue Injury)
Rest
Ice
Compression
Elevation
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1 min
Wound Drainage Types and Devices
Drainage Types
Serous
Serosanguineous
Sanguineous
Purulent
Drainage Devices
T-tube
Penrose
Jackson-Pratt (JP)
Hemovac
Considerations
Record Drainage Amounts
Check Device Function
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2 mins
Types of Wound Healing
Types of Wounds
Acute
Chronic
Healing Process
Primary Intention
Approximated Edges
Secondary Intention
Edges Not Approximated
Tertiary Intention
Delayed Closure due to Infection and Necrosis
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2 mins
Braden Scale
Characteristics
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
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2 mins
Interventions for Impaired Skin Integrity
Assessment
Signs of Skin Breakdown
Pain
Redness
Decreased Skin Turgor
Bleeding
Bony Prominences
Intervention
Reposition Q2H
Pressure Relief
Maintain Clean and Dry Skin
Adequate Nutrition and Hydration
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2 mins
Pressure Ulcers
Types
Stage 1 - Non-Blanchable Redness
Stage 2 - Partial Thickness
Stage 3 - Full Thickness Skin Loss
Stage 4 - Full Thickness Tissue Loss
Unstageable
Possible Deep Tissue Injury
Considerations
Skin Color Alterations
Remove Necrotic Tissue Before Staging
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2 mins
Guillain-Barre Syndrome Assessment
Assessment
Ascending Paralysis
Muscle Weakness
Paresthesias (Pins and Needles)
Diplopia
Difficulty Speaking
Dysphagia
Labile Blood Pressure
Loss of Bowel and Bladder Control
Considerations
Aggressive Airway Management
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2 mins

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