Agilbert485 Shared "NUR 214 Unit 1" - 33 Picmonics
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NUR 214 Unit 1
The Nursing Process
- ADPIE
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
2 mins
Assessment
- Health History
- Objective Data
- Subjective Data
- TEST-TAKING STRATEGY: KEY WORDS
- Identify
- Determine
- Obtain Information
- CONSIDERATIONS
- Assessment Always Done Before Treatments
3 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
2 mins
Planning
- Nursing Care Plan
- Tailored to Patient
- Short-and-Long-Term Goals
- SMART GOALS
- Specific
- Measurable
- Attainable
- Realistic
- Time-Oriented
2 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
3 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
2 mins
How to Write a NANDA Nursing Diagnosis
- Nursing Diagnosis
- Nursing Diagnosis Components
- Problem Statement
- Etiology
- Defining Characteristics or Risk factors
- 4 Types of Nursing Diagnoses
- Problem-Focused
- Risk
- Health Promotion
- Syndrome
- Steps For Writing a Problem-Focused Diagnosis
- (Problem-Focused Diagnosis) related to________(Related Factors) as evidenced by _____________ (Defining Characteristics).
- Steps For Writing a Risk Diagnosis
- Risk for_____as evidenced by_____(Risk Factors).
3 mins
NANDA Structure
- NANDA-I and Nursing Diagnoses
- NANDA-International (NANDA-I)
- Nursing Diagnoses
- Components of a Nursing Diagnoses
- Problem and Definition
- Etiology
- Defining Characteristics
- Risk Factors
- Nursing Diagnoses Domains
- Domains
3 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
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
Lung Sounds - Wheezes
- Location
- Throughout Lung
- Description
- High Pitched
- Sounds Like
- Musical
- Cause
- Air Moving through Narrowed Airways
38 secs
Lung Sounds - Crackles
- Location
- Lower Lobes
- Description
- Fine/Coarse
- Sounds Like
- Fine: Twisting Hair through Fingers
- Coarse: Velcro
- Cause
- Collapsed Small Airways and Alveoli "Popping Open"
1 min
Lung Sounds - Rhonchi
- Location
- Trachea and Bronchi
- Description
- Low Pitched Rumbling
- Sounds Like
- Gurgling
- Cause
- Narrowed Airway
- Secretions or Bronchospasm
49 secs
Lung Sounds - Pleural Friction Rub
- Location
- Anterior Lateral Lung
- Description
- Dry, Rubbing, or Squeaking
- Sounds Like
- Rubbing a Balloon with Finger
- Cause
- Inflamed Pleura
50 secs
Aortic Stenosis
- Characteristics
- Age-related Calcifications
- Bicuspid Aortic Valve
- Crescendo-decrescendo Murmur
- Systolic Murmur
- Ejection Murmur
- Ejection Click
- Radiates to Carotids and Apex
- Pulsus Parvus et Tardus
- Syncope
- Helmet Cells
2 mins
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