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20 Cards in this Set
- Front
- Back
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Enter Mneumonic
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Enter
Wash Intro Glove ID patient |
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Fluid Management
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Hydration Status
IV fluid verify Pump setting Palpate site IV tubing Check enteral feeds Orals explained Write it on PCS form |
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Mobility
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Mobility status
Observe abnormalities Balance/Devices Increase support Log their response Evaluate |
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Safety
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Siderails up
Phone/Call light Everything OK? Low/Locked Bed Lights on/off Socks on |
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Respiratory Assessment
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Breathing Pattern
Rate/Rythmn Equip/Explain Auscultate Tell them to breathe deep Hear x 4 Eval Sats (if required) |
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Peripheral Vascular Assessment
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Pulses
Edema Refill Inspect the wiggle Pink/Pale Hot/Cold Sensations? |
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Neurological Assessment
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Level x 3
Observe PERL Grips Inspect Fontanel (child) Check flex against resistance Symmetry/Movement (child) |
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Abdominal Assessment
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Privacy
Position (flat, knees bent) Pee? Pain? Suction Off Look Listen Feel Suction On |
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Skin Assessment
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Temperature
Wet/Dry Integrity Color Edema 2 areas |
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Respiratory Management
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Breathing Pattern
Rate/Rhythmn Equip/Explain Ascultate Tell them deep breaths Hear x 4 Eval response Emesis basin Assess readiness Suction (if assigned) IS or DBC Eval breath sounds Record effectiveness |
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Oxygen Management
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Sats
Humidity Observe nares/ears Reposition up Tolerance to activity Amount of O2 Ignition sources Refill/Color/Clubbing |
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Pain Management
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Pain scale
Assess location Intensity/Description of pain Need to reassess at 20 min Massage Guide/distract Medicate Turn them Temps (hot/cold app) 3 to do |
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Comfort Management
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Assess comfort
3 interventions Reposition Dental hygiene Cold/Hot application Hygenic (face, hands) Arrange linens Narcs/Nsaids Comfort rub Environment adjustments Record it all |
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Musculoskeletal Management
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Mobility status
Abnormalities Devices/Balance Pain Apply hot/cold ROM x 2 types Traction? |
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Wound Management
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Wound location
Observe drainage/condition Unique irrigation/supplies Not sterile/sterile? Dressing change Eval response/pain Document it |
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Specimen/Drainage
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Specimen collect
Place tube Examine specimen Clean area I/O record Assess site/tolerance Label ans send |
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Medications
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MAR check
Approp dose? Recheck MAR to ID Do the 5 rights Observe allergies Special asst needed (BP/P) Ask how they take Gather supplies Eval and admin Sign the MAR |
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Irrigation
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Solution
Temp (room) Other equip need (basin,chux) Position for draining Flow slow Look at return Observe tolerance Write it down |
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Patient Teaching
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Learning Ready?
Eval what they know Act of learning Reassess what you taught Need to record it |
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Enteral Feedings
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Feeding type
Low fowlers Orient patient Warm to room temp Select device Total amount On time Measure placement Aspirate/Air Check residual Have baby burp |
