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23 Cards in this Set
- Front
- Back
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FIRST THING
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I WISH I COULD GET EXCELSIOR.....
-INTRODUCE -WASH HANDS -ID PATIENT -COMFORT QUESTION -GLOVE -EXPLAIN (DO 20 MIN CKS) |
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FLUID MANAGEMENT
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...TO GO SIGN A PAPER KINDLY EXPLAINING I OBVIOUSLY WON’T REPEAT
-TURGER -GLOVE -SITE (VERBALIZE NO EDEMA) -ASEPSIS (UNGLOVE, SANITIZE) -PARENTERAL(CORRECT FLUID AND RATE -KARDEX COMPARISON -ENTERAL CORRECT FLUID AND RATE) -I/O (ALL LIQUIDS ON TRAY, OFFER FLUIDS X1, UNLESS RESTRICTED) -O2 CHECK -WASH -RECORD |
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MOBILITY
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MAKE DAILY ACTIVITES SPECIAL ALTERING PAIN, POSITION THEN AMBULATE REQUIRING SLIPPERS
-MOBILITY LEVEL -DEVICES -ABNORMALITIES IN BALANCE -SUPPORT -ALILGNMENT -PAIN WITH MOVEMNET -POSITION -TRANSFER, TURN OR -AMBULATE -RESPONSE -SLIPPERS |
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VITAL SIGNS
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-TEMP
-RESP. -PULSES -BP -O2 CHECK -WT -PAIN ***CHECK TWICE, WRITE BASLINE VITALS*** |
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ABDOMINAL ASSESSMENT
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3P'S LOOK LISTEN FEEL, DART
-PEE, POSITION, PAIN -LOOK -LISTEN -FEEL -DISTENTION -ABD. SOUNDS -RIGIDITY -TENDERNESS |
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NEURO ASSESSMENT
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LAMP
-LOC X 3 -ASSESS FONTANEL <1 -MOVEMENT (BIL. GRASPS, FLEXON) -PERRL |
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PERIPHERAL VASCULAR ASSESSMENT
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PLEASE BE SURE TO CHECK MOVEMENT CAPILLARY REFILL
-PULSES -BILATERALLY -SENSATION -TEMP -COLOR -MOVEMENT -CAP REFILL -RECORD |
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RESPIRATORY ASSESSMENT
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PAIR
-POSTION -ASSESS (RATE RHYTHM SOUND) -INSTRUCT (TO DEEP BREATHE IN AND OUT SLOWLY) -RECORD (ABNORMAL/NORMAL, O2 SAT IF ASSIGNED) |
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SKIN ASSESSMENT
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TIME 2 COLOR
-TEMP -INTEGRITY -MOISTURE -EDEMA - 2 AREAS -COLOR |
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MEDICATION ADMINISTRATION
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MASK IF RPM <30
-MAR -ALLERGIES, APICAL PULSE(IF NEEDED) -SELECT MEDS -kARDEX &KEEP EE ON MEDS -ID PT -FIVE RIGHTS -RECORD/RESPONSE ON -PCS FORM AND -MAR WITHIN -30 MINS |
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RESPIRATORY MANAGEMENT
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PLEASE REASSESS IMMEDIATELY AFTER SO PATIENT REGAINS REGULAR RATE
-POSITION (UPRIGHT) -RECEPTICLE -INSTRUCT (DEEP BREATHE IN AND OUT SLOWLY) -ASSESS (RATE RHYTHYM SOUND) -SPLINT -PERFORM MEASURE -REASSESS -RESPONSE -REAPPLY O2 IF REMOVED |
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COMFORT MEASURES
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COMFORT REDUCES AMOUNT MEDS WILL BE HAD REGULARLY
-COMFORT NEEDS +3 MEASURES -REPOSITION -ADJUST LINEN -MEDICATE OR NOTIFY NURSE -WASH (FACE OR ORAL CARE) -HEAT/COLD PACK -RESPONSE (REMOVE HEAT IN 20 MINS) |
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MUSCULOSKELATAL MANAGEMENT
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MOVING DEVICES ALWAYS SUPPORT ALIGNMENT PROPERLY PROVIDING THE AMBULATORY REASSURANCE REQUIRED
-MOBILITY LEVEL -DEVICES -ABNORMALITIES/ATROPHY -SUPPORT -ALIGNMENT -POSITION -PAIN -TRACTION -APPLY (DRVICE, TX, HEAT/COLD) -ROM (UP, OUT, IN) -RESPONSE (REMOVE HEAT IN 20 MINS) |
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OXYGEN MANAGEMENT
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CAN SOME PEOPLES OXYGEN SAT HAVE FALLEN AFTER RUNNING
-COMPLIES WITH GUIDELINES -SKIN UNDER TUBING -POSITION (HOB UP) -OBSERVE NAIL BEDS -SATURATION -HUMIDIFICATION -FLOW RATE -ASSESS RESPONSE TO ACTIVITY -RECORD |
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PAIN MANAGEMENT
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RATE LOCATION, QUALITY, DURATION PAIN, RELAX, REPOSTION, BRING HEAT, MEDS REASSESS RECORD
-RATE OF PAIN -LOCATION -QUALITY -DURATION -PAIN RELIEF (3 MEASURES) -RELAX -REPOSTIONS -BACK RUB -HEAT/COLD PACK (IF ORDERED) -MEDICATE REASSESS -RECORD |
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WOUND MANAGEMENT
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LEAVE THE AM DRESSING INTACT PLEASE TO REDUCE REGULAR REACTION
-LOCATION -TYPE -APPERANCE -DRAINAGE -IRRIGATION (IF ORDERED) -PACKING (IF ORDERED) -TOPICAL (IF ORDERED) -DSG CHANGE (DATE, TIME, INITIALS) -RESPONSE -RECORD |
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PATIENT TEACHING
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READ WHAT PATIENT UNDERSTANDS
-REDINESS TO LEARN -WHAT IS BEING TAUGHT -PATIENTS UNDERSTANDING |
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DRAINAGE COLLECTION
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ALL CLOUDY ICE MELTS RAPIDLY AND RUNS
-ASSESS (COLOR, AMT. ODOR CONSISTANCY) -CLEAN SURROUNDIGN TISSUE (IF ORDERED) -MAINTAIN POSITION/PATENCY -REMOVE TUBE (WHEN ORDERED) -RECORD |
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SPECIMAN COLLECTION
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OBTAIN LEVELS OF HIGH WATER READINGS
-OBTAIN SPECIMAN -LABEL PROPERLY -OBSERVE (COLOR ODOR CONSISTANCY -HOW SPECIMAN COLLECTED -WHERE IT IS GOING -RECORD |
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ENTERAL FEEDING
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FOR PROPER CALORIC REQUIREMENTS BEEP A RESIDENT RIGHT
-FEEDING TYPE -POSITION -CK PLACEMENT (NGT AIR AND ASPIRATION) -REINSTILL CONTENTS -BURB <6 MO -AT ROOM TEMP -RECORD TYPE, STRENGTH, AMOUNT -RECORD VOLUME OF GASTRIC RESIDUAL |
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INTERMITTENT FEEDINGS
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EASILY CK CK CK, READ DO BECOME AN RN
-ENTERAL FEEDING -CHECK GTTS -CK PLACEMENT (NGT AIR AND ASPIRATIONG) -CK RESIDUAL -REINSTILL RESIDUAL -DETERMINE AMT -BEGIN WITHIN 30 MINS -READJUST FLOW RATE/ RECORD AMT AND RESIDUAL |
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IRRIGATION
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SELECT THE PATIENT, VOLUME READY INSTILL RECORD
-SELECT SOLUTION -TEMP -POSITION -VERIFY TUBE PLACEMENT -RECEPTICLE -INSTILL SLOWLY -RECORD (SOL. TYPE, AMT, HOW PT TOLERATED |
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EXIT
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BE SAFE, PAY CLOSE ATTENTION WITH THE RECORDING
-BED LOW -SIDE RAILS UP -PHONE IN REACH -CALL LIGHT IN REACH -ASK COMFORT QUESTION --WASH HANDS -THANK PT -RECORD |
