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15 Cards in this Set
- Front
- Back
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First Thing
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WIGAS
Wash Hands Id/ Introduce Glove, prn Ask Comfort Safety Do 20 min checks |
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Fluid Mang
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That dripping oxygen sound is ridiculous.
Turgor/ Fontanels Drip rate O2 Check Site Check- Check tubing,solution, exp date I/O Record |
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Mobility
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All ambulatory patients should take baths regularly.
Assess Mobility Assistive Devices Position Support/ Safety Transfer/ Traction Balance/ Posture Abnormalities Record |
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Exit
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Be safe, Pay close atention when time recording.
Bed low Side rails up X_ Phone in reach Call Bell in reach Ask Comfort Wash Hands Thank Patient Record |
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Abd Assessment
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3 please, look, listen & feel my ribs.
Pee Position Pain Look Listen Feel Measure girth, if ordered Record |
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Neuro Assessment
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Lock pearls for me near river.
LOC PERL Fontanels Motor Response- Hands grasp AND foot flexion Noxious stimuli- child <3 yrs or noncommunicating adult Record |
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PVA
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PMS causes tension.
Pulses Movement Sensation Cap refill Temp BILATERAL |
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Resp Assessment
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PAIR.
Position Assess rhythm, rate & depth Instruct to DB (do b4 assess) Record normal - abnormal O2 sats, if ordered |
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Resp Mang
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Please reassess after preforming rescue relief.
Position Receptacle Assess rhythm, rate, depth Perform a measure (cough & DB or IS) Reassess Record A-I-R Assessment Intervention Response |
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O2 Mang
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An old persons face has a silly saturation record.
Assess response to activity Observe nail beds (cap refill or observation) Position HOB up Flow rate Humification Articles of Hazard Skin under tubing Sats, if ordered Record |
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Comfort Mang
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All observation deserve recording.
Ask Observe Do 3 measures Reassess |
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Musculoskeletal Mang
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MAP I A
Movement, level of Abnormalities Pain on movement Intervention Assess Response |
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Skin Assessment
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Assess charting in timely efficient manner.
Assess Color Integrity Temp Edema Moisture (minimum of 2) |
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Pain Mang
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Regular meds comfort, reassess response.
Rate pain Medicate/ Make RN aware Comfort measure Reassess Response |
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Medication
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Some must prescribe a med.
Select med Measure dose Patient ID Adminster within 30 mins MAR documentation within 30 mins |
