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13 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Wash hands
Introduce self/ID pt/I & O Glove Assess IV site, Fluids, Rate Ask pain Skin turgor, Safety, Save Tray |
20 MINUTE CHECKS
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WIGAAS
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Balance
Extraneous Movement Alignment & Assistive Devices Move to alignment Response of patient |
MOBILITY
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BEAMR
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Bend knees/Keep flat
Examine abd. (scars/colostomy) Listen Lightly palpate Your waist size (if assigned) |
ABDOMINAL ASSESSMENT
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BELLY
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LOC
Open eyes (PERRLA) General child's question Inspect fontanel Calculate motor function(symmetry or squeeze hands/dorsi,plantar flexion) |
NEURO ASSESSMENT
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LOGIC
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Pulses feel bilaterally
Examine skin Refill capillary Inspect temp Pt touch test Has movement |
PERIPHERAL VASCULAR ASSESSMENT
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PERIPH
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Always position in fowler's
Inspect symmetry/pattern Report labored breathing Watch for nasal flaring Ausculate 3levels Your done |
RESPIRATORY ASSESSMENT
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AIRWAY
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Skin color
Keep dry Integrity (rash/lesions) Needs braden scale edema |
SKIN ASSESSMENT
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SKIN(e)
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Assess comfort level
Observe patient Do 3 Reassess comfort level Record |
COMFORT MANAGEMENT
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AODRR
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Joint flexibility
Observe muscle strenth Initiate ROM Notice supportive devices Traction/Treatment hot or cold |
MUSCULO-SKELETAL MANAGEMENT
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JOINT
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Always position in Fowler's
Inspect equipment and skin Record sats and flow rate Observe 3 C's(cap refill/clubbing/color) 2 responses to activity |
OXYGEN MANAGEMENT
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AIRO2
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Pain scale
Area of pain Interventions Need to reasess and record |
PAIN MANAGEMENT
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PAIN
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Always position in fowler's
Inspect symmetry/pattern Report labored breathing Watch for nasal flaring Ausculate 3levels Your done Assigned C/DB Incentive Spirometry Reassess after CDB/IS Suction |
RESPIRATORY MANAGEMENT
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AIRWAY+AIRS
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Wound drainage
Observe site Unique clean/irrigation Need sterile field Dressing |
WOUND MANAGEMENT
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WOUND
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