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
2 mins
Registered Nurse Roles
- Nursing Roles in All Settings
- Caregiver
- Counselor
- Educator/Teacher
- Communicator
- Advocate
- Leader
- Researcher
- Collaborator
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
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
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
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 (94%-100%)
- Pulse (60-100)
- Blood Pressure (<120/80)
- Pain
2 mins
I-SBAR-R
- Identify
- Situation
- Background
- Assessment
- Recommendation
- Readback
1 min
5 Rights of Delegation
- Right Task
- Right Circumstance
- Right Person
- Right Direction/Communication
- Right Supervision/Evaluation
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
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
2 mins
Planning
- Nursing Care Plan
- Tailored to Patient
- Short-and-Long-Term Goals
- SMART GOALS
- Specific
- Measurable
- Attainable
- Realistic
- Time-Oriented
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
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
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
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
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
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
2 mins
Routes of Administration Part Two (Parenteral)
- Parenteral Administration
- Intradermal
- Subcutaneous
- Intramuscular (IM)
- Intravenous
- Epidural
- Intrathecal
- Intraosseous
- Intraperitoneal
2 mins
Braden Scale
- Characteristics
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
2 mins
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
1 min
