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22 Cards in this Set
- Front
- Back
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RESPIRATORY ASSESSMENT
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UBREATHE UPRIGHT POSITION BREATHING PATTERN RATE/RHYTHUM EQUIPTMENT (STETHOSCOPE/PILLOW) AUSCULTATE THROUGH NOSE OUT THROUGH MOUTH HEAR X4 ANTERIOR OR POSTERIORLY EVALUATE&RECORD |
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ABDOMINAL ASSESSMENT
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4P'S LLF SRR PRIVACY PEE PAIN POSITION SUCTION OFF LOOK LISTEN FEEL SUCTION ON REPOSITION RECORD |
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NEUROLOGICAL ASSESSMENT |
LOGICSS LOC (PERSON,PLACE,TIME) OBESERVE PUPILS GRASP INSPECT FONTANEL CHECK DORSI/PLANTAR FLEXION STIMULI (NOXIOUS FOR UNCONCIOUS PT) SYMMETRY OF MOVEMENT (CHILD) |
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PNVA
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PERIPH PALPATE PULSES BILATERAL EXTREMITY(UPPER OR LOWER?) REFILL (CAPILLARY) IS THERE SENSATION WITH EYES CLOSED? PALE/PINK HEAT/COLD |
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SKIN ASSESSMENT |
SKINNED ASHEETS SKIN COLOR KEEP WARM AND DRY INTEGRITY/INTACT NOTE EDEMA NEED REPOSITION EVALUATE PAIN DO 2 AREAS ANAL SKIN FOLDS HEAD EARS ELBOWS TROCANTERS SACRAL/COCCYXGEAL |
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RESPIRATORY MANAGEMENT
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UBREATHEEASIER UPRIGHT POSITION BREATHING PATTERN RHYTHUM/RATE EQUIPTMENT PILLOW,EMESIS,STETHOSCOPE ASSESS DB ANS ACCESARY MUSCLES TIMING HEAR POSTERIOR 4 AREAS EVALUATE 02 IF ASSIGNED EEMESIS BASIN ASSESS BREATHING SUCTION IF ASSIGNED INCENTIVE OR DB&C EVALUATE AGAIN RECORD |
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PAIN MANAGEMENT
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PAINEDMGMTT PAIN SCALE ASSESS LOCATION OF PAIN INTENSITY AND DISCRIPTION OF PAIN NEED TO REASSESS 20-30MINS AFTER EXACERBATION DURATION(ONSET? HOW LONG LAST?) MASSAGE GUIDE OR DISTRACT MEDICATION TURN (REPOSITION) TEMP(HEAT/OR COLD) PICK 3 OF MGMTT TO DO |
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MUSCULOSKELTAL MANAGEMENT
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MAD PART MOBILITY STATUS ABNORMALITIES DEVICES AND BALANCE PAIN APPLY HEAT/COLD RANGE OF MOTION TRACTION |
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Oxygen management |
Stop copd SET 02 RATE TEMP/HUMIDITY OBSEVE COLOR/CLUBBING PREVENT SPARKS COLOR/CONDITION OF SKIN 02 SAT POSITION TOLERANCE DOCUMENT |
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WOUND MANAGEMENT |
WOUNDED WOUND LOCATION OBSERVE DRAINAGE/TYPE/AMOUNT UNIQUE IRRIGATION AND SUPPLIES NEED CLEAN OR STERILE FIELD DRESSING CHANGE EVALUATE PAIN/TOLERANCE DOCUMENT WHAT YOU DID, THE FINDINGS, AND TOLERANCE |
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Comfort management |
A 3RD CHANCER ASSESS COMFORT 3 COMFORT MEASURES REPOSITION DENTAL HYGIENE COLD/HEAT HYGIENE ARRANGE LINENS NSAIDS OR OTHER SYMPT MEDS(ITCH, NAUSEA ETC) COMFORT RUB ENVIRONMENTAL ADJUSTMENTS RECORD (EVAL, MEASURES, RE-EVALS ) |
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IVP STATION |
MMMIPA MAR MED MATH INSPECT PALPATE ASPIRATE |
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WOUND STATION |
WOUND |
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IM/SUBQ |
WHEN WASH HANDS MIRAINDA MAR MAKES MED MASTERPIECES MATH ROLLING ROLL COLORED CLEAN VIALS AIRBRUSHES AIR DRAWING DRAW ROSES RECAP LOOSLEY IN ID GARDENS GLOVE CAPPED CLEAN IN INJECT PRETTY PRESSURE (GENTLE 2X2) SNOWFLAKES SIGN MAR VG 1 1/2 INCH VL 1 INCH |
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IVPB STATION |
WMMMIGIGACDCCS
WHEN. WASH HANDS MOM. MAR MADE. MED MONEY. MATH IN. ID GROWING. GLOVE INVESTMENT. IV G A. AIR IN LINE? CLEAR. CLAMP LINES DEPOSIT. DROP PRIMARY CHECK. CHANGE 2NDARY CAME. CALCULATE DRIP SATURDAY. SIGN MAR |
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SPECIMEN COLLECTION
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COLD TACT
Collect OBSERVE drainage LOCATION Drainage
Type Amount Color Tolerance |
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ROOM EXIT |
SPELLS
Siderails Phone calllight E Low locked Lights Say thank you
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HYDRATION 20 min check |
HIPPICOWS
HYDRATION STATUS IV Palpate Pump Inspect tubing Check enteral feeding Oral fluids explain Write it down Socks |
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MOBILITY |
MOBILE
Movement Observe alignment Balance devices I Log response Evaluate |
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ENTERAL FEEDINGS |
FLOW STOMACH R&R FEEDING TYPE LOW FOWLERS ORIENT PATIENT WARMTH OF SOLUTION ( ROOM TEMP) SELECT DEVICE TOTAL AMOUNT ON TIME MONITOR FEEDING DURING PCS ASSESS SKIN AROUND NG/ GTUBE CHECK RESIDUAL HAVE BABY BURP REASSESS RECORD |
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Every assessment and management |
SHEEP
S H Equiptment Explain P |
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Meds |
MAR DOSAGES MAR CHECK MED APPROPRIATE DOSE RECHECK MAR TO ID DO 5 RIGHTS OBSERVE ALLERGIES SPECIAL ASSESSMENT ASK HOW TAKE MED GATHER INFO EVAL AND ADMIN SIGN MAR |
