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15 Cards in this Set
- Front
- Back
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FIRST 20 MINUTES TO COMPLETE
INITIALLY WHEN PCS BEGINS |
WIGAAM
W=WASH I=ID PT G=GLOVES ON A=ASSESS ALL TUBES- IV/NGT/O2 A=ASSESS IV SITE -RATE-RIGHT M=MOUTH CHECK HYDRATIONS |
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FLUID MANAGEMENT
FIRST 20 MINUTES |
PIE-EAR
P=PALPATE IV SITE/RATE AND IV I=INSPECT MOUTH E=ENTERAL-MEASURE ALL PO IN E=EMPTY OUT ALL FLUIDS/EXPLAIN A=ASPIRATE NGT/PLACEMENT & IV R=RECORD AS YOU DO IT ALL |
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VITAL SIGNS
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T=TEMP-RECORD ORAL/TYMP/AXIL
P=PULSE DO 1 MIN. APICALLY R=RESP COUNT 1 FULL MIN BP=BLOOD PRESSURE 1ST/LAST P=PAIN SCALE 0-10 FACES FLACC O2=MEASURE O2 SATS(PARAMETERS) WT= WEIGH PT UNDRESS B/B/C BALANCE/BARRIER/CLEAN |
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MOBILITY
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LAB-PTP
L=LEVEL OF MOBIL ABLE TO MOVE A=ASSISTIVE DEVICES B=BALANCE P=POSITION W/GOOD POSTURE T=TOLERATES TRANSFER/MVMT P=PT STATED "IM READY TO ... |
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ABDOMINAL ASSESSMENT
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SOME PPL PLAY LIKE LITTLE FARTS
S=SXN OFF P=PEE P=POSITON PT FLAT L=LOOK (SCARS/DRSGS) L=LISTEN X 4 QUADS 1MIN F=FEEL LIGHT PALP/PAIN ON PALP |
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NEURO ASSESSMENT
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LOCATE PUPILS PUSH MOTOR NEURONS
L=LOC PERSON/PLACE/TIME P=PUPILS PERRL P=PUSH BABYS FONTANELE M=MOTOR RESPONSE SYMETRY/MVMT N=NOX STIMULI-NAILBED PRESSURE |
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PERIPHERAL VASCULAR ASSESSMENT
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PULSES CAN CAUSE TOES TO WIGGLE
P=PULSES BILAT C=COLOR C=CAP REFILL T=TEMP WARM/COOL T=TOUCH/TACTILE CAN YOU FEEL.. W=WIGGLE TOES/FINGERS |
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RESPIRATORY ASSESSMENT
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PLEASE ASSESS OMAR
P=POSITION UPRIGHT A=AUSCULATE UPPER/LOWER(BONES) O=OBSERVE PATTERN SHALLOW... M=MEASURE O2 SATS A=ABNORMALS DOE/SOB@REST/WALK R=RECORD |
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SKIN ASSESSMENT
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CIT=EMAR 2 SKIN AREAS
C=COLOR I=INTEGRITY RASH/LESIONS/DRGS) T=TEMP E=EDEMA A=ALL EXPOSED SKIN CHECKED R=RECORD/REPO PT OFF AREA |
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MUSCULOSKELETAL MANAGEMENT
AIR IN EFFECT |
AMP=PAAMP
ABNORMAL MOBILITY IS PAINFUL PERFORM 1 APPLY DEVICE/ APPLY ICE/HOT MAINTAIN TXN PT STATES A=ABNORMALS / ATROPHY/CVA M=MOBILITY P=PAIN P=PERFORM A/PROM A=APPLY DEVICE (CPM/SLING) A=APPLY ICE/HOT (BARRIER) M=MAINTAIN TXN P=PT STATES |
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PAIN MANAGEMENT
AIR IN EFFECT |
ALEVE MAY PROVIDE REAL RELIEF
A=ASSESS PAIN SCALE 0-10 M=MEDICATE P=PROVIDE REPO/TV/HOT/COLD R=REASSESS IN 30-45 MIN R=RECORD |
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OXYGEN MANAGEMENT
AIR IN EFFECT |
AIR(ACTIVE)N O2 SOMETIMES PEELS MY SKIN
A=ACTIVITY RESPONSE N=NAILBEDS CK;TISSUE PERFUSION O2=O2 SATS S=SKIN SURFACES P=POSITION/POSTURE RIGHT S=SAFETY |
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RESPIRATORY MANAGEMENT
AIR IN EFFECT |
PR-AIR
P=POSITION SITTING UP R=RECEPTACLE A=ASCULATATE I=INSTRUCT CDB/IS R=REASSESS IMMEDIATLY AFTER |
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WOUND MANAGEMENT
AIR IN EFFECT |
AIR-CAD
A=ASSESS WOUND DRNG/COLOR/LOC I=IRRIGATE RIGHT STUFF/TEMP R=RECEPTACLE(DONT CONTAMINATE) C=CLEANSE A=APPLY TOPICAL D=DATE DRESSING |
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COMFORT MANAGEMENT
AIR IN EFFECT |
ASK PEOPLE 3X TO RELAX
A=ASK ASSESS COMFORT LEVEL P=PERFORM 3 BMB/MEDICATE/REPO DO WHATEVER ASSIGNED R=REASSESS COMFORT LEVEL |
