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23 Cards in this Set
- Front
- Back
- 3rd side (hint)
ABDOMINAL ASSESSMENT
4P'S LLF 4'R |
PRIVACY
PEE PAIN POSITION SUCTION OFF LOOK LISTEN FEEL REPOSITION RESONSE RECORD SUCTION ON |
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NEUROLOGICAL ASSESSMENT
LAMPN4NR |
LOC ORIENTED X 3
ASSESS FONTANEL <1 MOVEMENT GRASP AND PLANTAR FLEXION AGAINST RESISTANCE PERL NOXIOUS STIMULI 4 NONRESPOSIVE R/R |
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PERIPHERAL VASCULAR ASSESSMENT
PERIPH |
PULSES
EDEMA REFILL - CAPILLARY INSPECT SENSATION/MOVEMENT PALE/PINK HOT/COLD |
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RESPIRATORY ASSESSMENT
BREATHE |
BREATHING PATTERN LABORED/UNLABORED
RHYTHM AND RATE EXPLAIN PROCEDURE AND EQUIPMENT ACCESSORY MUSCLES USED? TELL TO TAKE SLOW DEEP BREATHES HEAR IN FOUR SPOTS POSTERIOR EVALUATE 02 AND RECORD INCLUDE RESPONSE |
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SKIN ASSESSMENT
A SHEET O |
ANAL
SACRAL HEELS EARS ELBOWS TROCHANTER OTHER |
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SKIN ASSESSMENT
SKINNED |
SKIN COLOR
KEEP W/D INTREGRITY NOTE EDEMA NEED TO REPOSITION EVALUATE PAIN DO 2 AREAS R/R RESPONSE AND RECORD |
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MUSCULOSKELETAL MGMT
MAD TRAP |
MOBILITY LEVEL
ABNORMALITIES-PTSDB DEVICES APPLIED TRACTION ROM IN AB/ADDUCTION OR FLEX/EXT IF ASSIGNED APPLY HEAT COLD IF ASSIGNED PAIN WITH MOVEMENT R/R |
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MUSCULOSKELETAL
PTSDB |
POSTURE
TREMORS STEADY DIZZY BALANCE |
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OXYGEN MANAGEMENT
A SHORT AIR |
ASSESS NAIL COLOR/CLUBBING/CAP REFILL
SATS HUMIDITY IF ASSIGNED OBSERVE SKIN CONTACT POINTS REPOSITION UP TOLERANCE TO ACTIVITY AMOUNT OF 02 RATE AND DELIVERY METHOD IGNITION SOURCES RESPONSE TO REPOSITIONING/ACTIVITY R/R |
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COMFORT MANAGEMENT
A 3RD CHANCER |
ASSESS COMFORT LEVEL
3 COMFORT MEASURES REPOSITION DENTAL HYGIENE COLD/HEAT HYGIENE FACE/HANDS ARRANGE LINENS NSAIDS, NARCOTICS COMFORT RUB ENVIRONMENTAL ADJUSTMENTS RECORD-EVAL/MEASURE/RE-EVAL |
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PAIN MANAGMENT
P (LTD) AIN |
PAIN LEVEL (LTD)
-LOCATION -DURATION -TYPE ASK PRIMARY FOR RX CHART IMPLEMENT 3 INTERVENTIONS NEED TO REASSESS AND CHART ALL |
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RESPIRATORY MANAGEMENT
BREATHE EASIER |
BREATHING PATTERN LABORED/ UNLABORED
RHYTHM AND RATE EXPLAIN PROC AND GET EQUIP ACCESSORY MUSCLES USED? TELL TO TOAKE SLOW DEEP BREATHS HEAR IN 4 SPOSTS POSTERIOR EVAL 02 AND COMFORT EMESIS BASIN AND TISSUE WITH GLOVES ASSESS BREATHING SUCTION IF ASSIGNED INCENTIVE, DB & COUGH PERCUSSION IF ASSIGNED EVALUATE AGAIN R/R |
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WOUND MANAGEMENT
WOUNDED |
WOUND LOCATION AND TYPE
OBSERVE DRAINAGE (COCA) UNIQUE IRRIGATION AND SUPPLIES NEED CLEAN OR STERILE? DRESSING CHANGE EVAL PAIN AND TOLERANCE DOCUMENT WHAT YOU DID FINDINGS AND TOLERANCE |
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IRRIGATION
STOP FLOW |
SOLUTION TYPE AND AMOUNT
TEMPERATURE WARM OTHER EQUIPMENT (CHUCKS RECEPTICLE GLOVES) POSITION FOR DRAINAGE FLOW RATE SLOW AND EASY OBSERVE RESPONSE WRITE IT DOWN |
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MEDICATIONS
MAR DOSAGES |
MAR MATH MED
APPROPRIATE DOSE RECHECK MAR TO ID DO 5 RIGHTS OBSERVE ALLERGIES SPECIAL ASSESSMENT ASK HOW THEY TAKE RX GATHER EQUIPMENT EVALUATE AND ADMINISTER SIGN MAR |
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ENTERNAL FEEDING
FLOW STOMACH |
FEEDING TYPE AND STRENGTH
LOW FLOWLERS MINIMUM ORIENT PT WARMTH (ROOM TEMP) SELECT DEVISES TOTAL AMT ON TIME MEASURE PLACEMENT AIR/ASPIRATE CHECK RESIDUAL HAVE BABY BURP R/R |
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DRAINAGE SPECIMEN
SPE (COCA) CIAL |
SPECIMEN COLLECTED
PLACE TUBE OR VERITY PLACEMENT EXAMINE (COCA) CLEAN SURROUNDING AREA I/O IF ASSIGNED ASSESS SITE LABEL AND SEND TO LAB R/R |
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PATIENT TEACHING
RID |
READINESS TO LEARN
IDENTIFY NEEDS AND INFORM PATIENT DOCUMENT READINESS, INFO, RESPONSE |
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SAFETY
SCABIES |
SIDE RAILS UP
CALL LIGHT IN REACH ANY QUESTIONS BED LOW AND LOCKED I/O'S EXPRESS GRATITUDE SANITIZE HANDS |
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ASK NURSE
OPALS |
OUT OF BED RECENT?
PAIN MEDS ANY REFUSALS LUNG SOUNDS STABILITY SINCE ADMIT |
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1ST THING IN ROOM
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EWIIG
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ENTER
WASH HANDS INTRODUCE SELF ID PATIENT GLOVES |
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20 MINUTE CHECK
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HIPPICOW
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HYDRATION STATUS
IV RATE AMT TYPE PALPATE SITE PUMP SETTING DROPS INSPECT IV TUBING CHECK ENTERAL FEEDING ORAL FLUIDS EXPLAINED WRITE DOWN FINDING SOCKS |
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SPECIMEN COLLECTION
COLD TACT |
COLLECT
OBSERVE-COCA LABEL-INITIAL TIME DATE DOCUMENT TYPE AMOUNT COLOR TOLERANCE |
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