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15 Cards in this Set

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  • Back
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
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
VITAL SIGNS
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
MOBILITY
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 ...
ABDOMINAL ASSESSMENT
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
NEURO ASSESSMENT
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
PERIPHERAL VASCULAR ASSESSMENT
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
RESPIRATORY ASSESSMENT
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
SKIN ASSESSMENT
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
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
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
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
RESPIRATORY MANAGEMENT


AIR IN EFFECT
PR-AIR
P=POSITION SITTING UP
R=RECEPTACLE
A=ASCULATATE
I=INSTRUCT CDB/IS
R=REASSESS IMMEDIATLY AFTER
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
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