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7 Cards in this Set
- Front
- Back
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First thing you do in 20 minutes
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Wash hands
id patient introduce self and ce ask general comfort questions glove check hydration iv check gel encourage or discourage intake and output |
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Mobility
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How do you ambulate?
Do you use assist devices to help you walk? Nonskid socks any abnormalities can i help you reposition? Transfer with support ambulate |
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Abdominal assessmt.
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Privacy
Pee position suction off look, listen, feel bowel sounds, tenderness, rigidity, distention Record |
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Neurological Assessment
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Loc
Pupils fontanel less than 1 year hand grasp check dorsiflexion and plantar flexion noxious stimuli for unresponsive patient symmetry with movement of child record- loc, fontanel, pupil response, equality of motor response |
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PVA
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Pulses
Edema Cap refill/color inspect sensation/movement temp |
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Skin assessment
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Skin color
keep warm Moisture intact/integrity note edema record |
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Respiratory
assessment |
Position upright
auscultate over upper and lower lobes systematically from side to side breathing patters (normal or abnormal) Tell patient to breathe in and out slowly and deeply oxygen saturation |
