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23 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Patient teaching |
L-learning readiness (assess motivation/ ID barriers) E- Evaluate prior knowledge A-ask questions to ID specific learning needs (method of learning) R-reassess understanding/ have pt repeat info back N- need to document
P- provide accurate information A- ask questions to determine understanding |
Learn Pa |
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Irrigation |
S-solution type ant T-temp (room temp) O-obtain species equipment (syringe & receptacle) P- position for drainage
A-aspirate & air (ng's)
F- flow rate slow and gentle L-look at return solution amt/color O- observe pt response W-write it down ( kind, amt, response) |
STOP A FLOW |
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Musculoskeletal mgmt |
M-mobility status (use of assistance) A-abnormalities (atrophy or contractures) D-devices (supportive/ therapeutic)
P-pain with movement A-apply heat/cold if ordered 20 mins protect skin R-range of motion (active or passive- abduction & adduction or flexion & extension) T-traction (verify wts, ropes unobstructed, pt correct alignment) E-evaluate tolerance R-response/record |
MAD PARTER |
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Oral or injection meds |
W-wash hands A-apical/bp check R-rightsx5 (pt/name/dob, drug, route, dose, time) check allergies M-med to room
W-wash hands I-ID pt to mar G-gloves on G-give med/ inj clean site apply pressure after S-sign mar |
WARM WIGGS |
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Drainage & specimen collection |
A-assess color of drainage & amt C-Clean area if assigned T-Tube replace as found T-tube drainage (maintains or attaches) R-record
O-obtain specimen C-correct container L-label date/time pt name C- correct location (lab) R-record
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ACTTR OCLCR |
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Wound Mgmt |
*Gloves* W-wound location type/apperance O-observe for drainage COCA (consistency, odor, color, amt) U-unique irrigation supplies (solution, 35ml syringe, receptacle, position pt) N-need clean area or sterile field (open packages away from you) D-dressing change/pack label with date time E-evaluate tolerance/pain D-document
P- protect wound- remove dsg w/o contaminating wound or injuring surrounding skin & the same with applying new dsg |
WOUNDED P |
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Pain Mgmt |
P-pain level/scale 1-10, 0-5 faces, flaccs/ behavior A-assess location I-intensity/quality sharp/dull D-duration
M-massage G-guided imagery/relax/distraction M-meds T-Temp hot/cold pack
T-Turn/ reposition R-reassess after 20 mins R-record response
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PAID MGMT TRR |
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Oxygen Mgmt |
B-best position (upright for proper respirations) R- resp rate/rhythm E-ears/nares for breakdown A-assess tolerance to activity T-triggers for combustion H-humidity if assigned E-evaluate 02 sat if assigned
A-Assess cap refill/color/clubbing F-finally E-evaluate & R-record (response, 02 sats & status, condition of skin, 02 measures) |
BREATHE sAFER |
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Skin Assesment |
T-temp hot/cold W-wet/dry I-integrity intact? C-color red/pink E-edema?
R-reposition off area E-evaluate for pain D-do 2 areas (heels, sacral, coccyx, occiput, trochanter, skin folds, perianal) R-record |
TWICE REDR |
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Neurological Assessment |
L-LOCx3 (time, place, name) O-observe pupils PERRL (pupils equal round reactive to light G-grasp hands simultaneously I-inspect fontanel 1yr or younger upright C-check plantar/dorsiflex feet simultaneously S-stimuli noxious for unresponsive- nailbed S-symmetry of movmt child R-record/response |
LOGICSSR |
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Medications |
M-Mar (get the mar) wash hands M-meds (check meds) M-measure/calculate wash hands
I-id pt against mar A-allergies S-special assessments (gloves on) A-administer meds S-sign mar |
M3 IASAS |
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Mobility |
S-status mobility/socks on A-abnormalities- balance/gait D-devices (cane, walker,crutches)
A-Assess for pain w/movmt I-implement activity/increase support R-reassess pt response R-record |
SAD AIRR |
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Vitals |
G-gloves T-temp P-pulse apical or radial R-respiratory rate B-b/p W-weight if assigned (use barrier on scale) O-o2 sat if assigned P-pain (what scale- 0-10, 0-5 faces, FLACCS) R-record |
GT PRB WOPR |
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Fluid Mgmt (20 min checks) |
H-hydration status- mucus membranes,skin turgor, fontanel I-IV type/rate/amt P-palpate iv site for edema/temp P-pump settings check I-inspect tubing for air C-check enteral feeding O-oral intake encourage/restrict W-write it down/record D-declare |
HIPPICOW D |
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Enter Room |
E-enter room W-wash hands I-introduce self/ce I-ID pt I-interaction purpose / explain why there G-gloves |
EWIIIG |
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Abdominal Assesment |
P-privacy P-pee have too? P-pain have any? P-position head down knees bent no more than 30* L-look for distention, scars, lesions, ect L-listen x4 quads F-feel tender/rigid x4 quads painful last R-reposition pt R-record |
4P LLF RR |
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Respiratory Assessment |
P-position pt upright/ on side if can be upright I-instruct pt to breathe normally B-breathing abnormalities/pattern R-respiratory rate/rhythm E-equipment clean A-auscultate x4 side to side upper and lower lobes posterior on skin T-tell pt to breathe slow and deep H-hear x4 E-evaluate 02 if assigned R-record/ response |
PI BREATHER |
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Peripheral Vascular Assessment |
C-compare pulses bilat M-motor- ask pt to move extremities P-pulse- presence/absence of most distal E-edema R-refill- cap refill bilat I-inspect for sensation w/ eyes closed P-pale/pink skin color H-hot/cold temp R-record |
CM PERIPH R |
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Safety/Exit |
S-siderails up C-call bell within reach A-anything else you need (lights on off) B-bed low and locked S-slippers/ non skid socks when walking |
SCABS |
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Comfort Mgmt |
A-assess level of comfort (ask/observe behavior) 3-3 things below R-reposition D-dental hygeine C-change linens H-hygeine activities A-apply cold/heat or offer blanket N-nsaids/meds C-comfort rub E-Enviromental controls- lights R-record pt response |
A 3RD CHANCER |
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Respiratory Mgmt |
P-position pt upright B-breathing pattern R-resp rate/rhythm E-equipment explain A-assess breathing T-tell pt to breathe in/out slowly deeply H-hear in 4 lobes side to side E-evaluate O2 if assigned E-emesis basin/ tissue for secretions A-assess breathing before & after interventions S-suction if assigned I- incentive spirometer deep breathing with cough on 3rd breath, chest percussion/vibe E-evaluate again- pattern, rate sounds R-record (bilat breath sounds before & after tx, breathing patterns, interventions implemented & pt response |
P BREATHE EASIER |
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IV MEDS |
R-record gtts/min or ml/hr on PCS before admin A-assess iv site for edema/temp C-clear air in tubing A-aspirate for blood F-flush before and after admin A-administer (after id pt to mar) R-record flush solution on pcs R-regulate flow R-record all of above |
RAC AFA 3R |
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Enteral feeding |
F-feeding type compare with kardex L-low fowlers position O-orient pt W-warm (room temp solution) S-select device T-total amt (intermittent tube feeding) O-on time +/- 30min initiate within M-measure/ calculate gtts A-aspirate & air (check placement if assigned 20-30ml air) C-check residual & reinstill H-have baby burp R-response R-record |
FLOW STOMACH RR |
