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19 Cards in this Set
- Front
- Back
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HIPPI
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H-handwash
I-Intro P-Patient's ID P-Put on gloves |
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IV (COW PTSD)
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C-check site
O-off gloves W-wash hands P-Pinch (Tur)/Palpate (Font) T-Tubing S-solution D-Drop count/ICD setting |
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Mobility
NEST-To Do WABLER-To Chart |
N-nonskid
E-Equipment S-Supp devices T-tolerate W-what did A-Assist devices B-balance L-level of mobility E-extraneous movement R-response of pt |
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Neurological Assessment
COPS |
C for infants < 1 only
C-check fontanel while upright O-orientation -PPT-person, place, time -VAT-Visual, auditory, tactile P-pupils PERRL-pupils equal, round, reactive to light S-strength bilaterally (extremity) |
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Abdominal Assessement
4 Ps PPPP SODA POP |
P-privacy
P-pee P-position P-pain S-suction off O-observe (distention, cont) D-don gloves A-auscultate-4 quadrants P-palpate 1-2 cms O-on suction P-per order, measue girth |
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Peripheral Vascular Assessment
GET P PMS (Get past PMS!) |
G-glove only if open sores
E-Edema (compare visually) T- temp P-pulses P-perfusion CCC- color, cap refill, clubbing M-motor S-sensation |
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Oxygen Management
FAN SHOP |
F-flow rate
A-activity N-nose S-safety H-humidification O-02 status CCCO-color, cap refill, clubbing, 02 sat P-position |
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Comfort Management
AIR (MD BMW CAR) |
A-assess
I-intervene MD BMW CAR M-medicate D-distract/Relax B-backrub M-mouth care W-wash face C-change/straighten linen A-apply heat/cold R-reposition R-response |
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Pain Management
AIR (MR BIRD) |
A-assess
I-intervene MR BIRD M-medicate R-reassess pain level B-back rub I-instill heat/cold R-reposition D-distract/relax R-reassess |
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Skin Assessment
SEPTIC M MOBS |
A-assess
SEPTICM-skin edema, pressure, ulcer risk score, temp, integrity, color, moisture I-intervene (not needed) MOBS M-moisture reduction O-offer food/fluid B-bony prominences S-shearing skin prevent R-response |
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Wound Management (Man)
AIR TALL-type CALIPPP |
Assess
TALL T-type Contusion, abrasion, laceration, incision, puncture, penetrating, pressure ulcer) A-appearance, L-location, L-look for drainage I-intervene R-response |
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IRRIGATION (Management)
AIR |
A-assess
I-Intervene STRIP- solution,temp, receptacle, irrigate (amount, return fluid) protect Dressing Change (DRDCALL) R-response |
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Drainage & Specimen Collection
DACT SOLD |
DACT
D-drainage A-assess C-cleanse T-tube SOLD S-specimen collection O-obtain L-label D-designated container/place |
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Patient Teaching (Man)
AIR |
A-assess (readiness to learn, learning needs or barriers to learning)
I-intervene (provide info) R-reassess (ask questions to find out if patient learned new information) |
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Respiratory Assessment
EPS SALT (Epsom salt) |
E-elevate HOB of not contraindicated
P-pattern + rate S-shallow S-sounds A-accessory muscles L-labored/Un T-tolerated assessment? |
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Respiratory Management:
GRAPES then AIR |
G-gloves on
R-receptacle A-arrange tissue P-position pt E-elevate HOB up if no contrain S-splint with pillow A-assess EPS SALT I-intervene DB/DB&C/CP/ Suction-SIRP Bulb syringe-DIA R-REASSESS EPS SALT |
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Muscular Skeletal Managemt
AIR |
A-assess
JAM-Joint and Muscle Sugar-strength Free-flexibility I-Intervene HATS H-heat/cold A-active/passive ROM T-traction S-supportive devices R-response |
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Safety
CABS |
C-call light
A-apply brakes B-bed in low position S-siderails up |
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Any time you step away from pt. OR step out of the room.
Remember to SWIM |
S-safety (CABS)
W-wash hands I-inscribe/record/write N/A where needed especially for 20 min check M-must tell RN |
