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23 Cards in this Set
- Front
- Back
- 3rd side (hint)
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ABDOMINAL ASSESSMENT
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4P'S LLF 4'R
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PRIVACY
PEE PAIN POSITION SUCTION OFF LOOK LISTEN FEEL REPOSITION RESONSE RECORD SUCTION ON |
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NEUROLOGICAL ASSESSMENT
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LAMPN4NR
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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
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PERIPH
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PULSES
EDEMA REFILL CAPILLARY INSPECT SENSATION/MOVEMENT PALE/PINK HOT/COLD |
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RESPIRATORY ASSESSMENT
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BREATHE
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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
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SKINNED
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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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SKIN ASSESSMENT AREA
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A SHEET O
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ANAL
SACRAL HEELS EARS ELBOWS TROCHANTER OTHER |
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MUSCULOSKELETAL MGMT
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MAD TRAP
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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
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PTSDB
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POSTURE
TREMORS STEADY DIZZY BALANCE |
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OXYGEN MANAGEMENT
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A SHORT AIR
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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
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A 3RD CHANCER
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ASSESS COMFORT LEVEL
3 COMFORT MEASURES REPOSITION DENTAL HYGIENE COLD/HEAT HYGIENE FACE/HAND ARRANGE LINENS NSAIDS, NARCOTICS COMFORT RUB ENVIRONMENTAL ADJUSTMENTS RECORD EVAL/MEASURES/RE-EVAL |
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PAIN MANAGMENT
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PAIN MGMTT
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PAIN SCALE
ASSESS LOCATION OF PAIN INTENSITY AND DESCRIPTION NEED TO REASSESS 20-30 MIN AFTER MASSAGE GUIDE DISTRACT MEDICATION TURN (REPOSITION) TEMP HEAT/COLD PICK 3 |
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RESPIRATORY MANAGEMENT
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BREATHE EASIER
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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
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WOUNDED
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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
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STOP FLOW
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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
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MAR DOSAGES
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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
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FLOW STOMACH
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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
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SPE (COCA) CIAL
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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
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LEARN
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LEARNING READINESS
EVALUATE KNOWLEDGE ACT OF LEARNING REASSESS UNDERSTANDING NEED TO RECORD |
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SAFETY
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SCABIES
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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
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OPALS
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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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EWIGG
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ENTER
WASH HANDS INTRODUCE SELF/CE ID PATIENT GLOVE |
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20 MINUTE CHECK
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HIPPICOW
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HYDRATION STATUS
IV RATE AMT TYPE PALPATE SITE- GLOVE PUMP - SETTING DROPS INSPECT IV TUBING CHECK ENTERAL FEEDING ORAL FLUID EXPLAIN WRITE DOWN FINDING SOCKS |
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SPECIMEN COLLECTION
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COLD TACT
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COLLECT
OBSERVE COCA LABEL- INITIAL DATE TIME DOCUMENT TYPE AMOUNT COLOR TOLERANCE |
