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18 Cards in this Set
- Front
- Back
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20 Minute Check
SHIPCOW |
S - Safety
H- Hydration I- IV fluids P- Palpate IV temp or edema C- Check enteral feed TART O- Oral explain I&O, diet restrictions W- Write and declare |
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Abdominal Assessment
PPPSLLF |
P- Pee?
P- Pain? P- Position S- Suction off L- Look L- Listen F- Feel |
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Respiratory Assessment
BRATO |
B- Breathing pattern
R- Rate Reg, Irregular A- Auscultate T- Tell Pt. to deep breath slowly O- O2 Sat if assigned |
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PNVA
PRIT |
P- Pulses
R- Refill I- Inspect sensation w eyes closed AND movement T- Temp |
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Skin Assessment
TWICED |
T- Temp
W- Wet/moisture I- Integrity C- Color E- Edema D- Do 2 areas |
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Neuro Assessment
LAPGPSS |
L- LOC person, place, time A- Assess fontanel P- Pupils G- Grasp hands P- Plantar/Dorsi flexion S- Stimuli non communicating adult/ S- Symmetry/movement non communicating adult/ |
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Medications
CARDSS |
C- Check MAR
A- Allergies R- Recheck patient ID D- Do 5 rights (Pt, time, drug, dose, route) S- Special assess HR,BP,RR S- Sign MAR Meds to be given w/in 30 min of scheduled time. |
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Comfort Management
ADR |
A- Assess
D- Do 3 interventions R- Reassess |
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Safety
CABS |
C- Call light
A- Ask Pt if need anything B- Bed low and locked S- Side rails up |
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Mobility
SLAB |
S- Socks On
L- Level of Mobility A- Assisting devices B- Balance/Gait/Posture |
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Pain
PAIR |
P- Pain scale
A- Assess LTD- location, type, duration I- Implement 3 R- Reassess |
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Respiratory Management
BRAT DR |
B- Breathing pattern
R- Rate Reg, Irregular A- Auscultate T- Teel Pt. to deep breath slowly D- Do Resp hygiene: IS, DB&C R- Reassess |
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Oxygen Management
PAC SHOR |
P- Position Up
A- Amt O2 C- Cap refill S- Skin ears, nares, face H- Humidity O- O2 Sat if assigned R- Response/tolerance to (repositioning) |
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Musculoskeletal Assessment
MAPDIRR |
M- Mobility
A- Abnormalities P- Pain w movement D- Devices (CPM,Traction,Cast, Boot,etc.) I- Ice/heat R- Range of motion R- Response |
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Wound Management
SEFADR |
S- Supplies ( drsg, fluids, basin, towel, etc)
E- Explain/position Pt F- Field clean or sterile A- Assess LTAP location, type, appearance, presence drainage D- Dressing change R- Response Pt denied pain or discomfort before, during and after dressing change Document: location, type, appearance, presence drainage, what you did, pt's response. |
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Drainage LTACS |
L-Location T-Type A-Amount C-Color S- Skin/Dressing condition |
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Specimen LAB RAT |
L- Label container A- Attain Specimen B- Bring and place in designated container R- Record A- Appearance T- Type |
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Irrigation SAWR |
S- Solution Type and temperature A- Amount of solution W- Where R- Return |
