Robin Shared "Unit 1" - 7 Picmonics

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Unit 1

Stages of Hypothermia
Mild
32 to 35°C (90 to 95°F)
Shivering
Moderate
28 to 32°C (82 to 90°F)
Obvious Motor Impairment
Slowed Thinking
Severe
< 28°C (< 82°F)
Shivering Stops
Paradoxical Undressing
Arrhythmias
3 mins
Hypothermia Interventions
Remove From Environment
Remove Wet Clothing
Passive Rewarming
Warm Clothing
Active Rewarming
Heated Blankets
Warm IV Solutions
Heated Oxygen
Warm Gastric Lavage
Considerations
Warm Trunk BEFORE Extremities
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
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
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
The Nursing Process
ADPIE
Assessment
Diagnosis
Planning 
Realistic
Individualized to the Patient
Timed
Implementation
Evaluation
2 mins
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
1 min

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