Cpne Study

Front 1

S
O
A
P

Back 1

Oxygen Management
S - Skin Assessment - check the skin around canula, face mask. Intact?, Red?
O- Oxygen status: )2 sats, OR cap refill
A- Activity Level: Assess PT's response to activty. Tired?, SOB?
P- Position: Position PT to help facilitate breathing.

Front 2

TIME to check Color of skin

Back 2

Skin Assessment 2 areas
T - Temperature
I - Integrity: Is the skin broken or intact?
M - Moisture
E - Edema
Color

Front 3

Please make sure to check Cap refill

Back 3

Peripheral Vascular Assessment
P - Pulses present? Find the most distal pulses.
M - Movement: As the Pt to move extremities, or noting movement in : chiild <3 or non communicating adult.
S - Sensation: Did the Pt feel it when you squeezed their fingers/toes?
T - Temperature
C - Color
C - Capillary refill

Front 4

LAMP

Back 4

Neurological Assessment
L - LOC: Ask the pt to name: Person Place and Time
A - Assess fontanel: In upright position if < 1 Y.O. (flat,bluging, depressed)
M - Movement: Hand grasp/push down and up AND pedal push/pull

Front 5

RAT FEVER

Back 5

Enteral Feeding
R- Record:
A- Amount of formula AND
T - Type of formula
F - Fowlers: Position in folwers first to receive the tube feeding
E - Examine gastric tube/abdomen
V - Verify placement of NG tube by first aspirating gastric contents AND then instilling 20 mL air bolus and listening
E - Expiration date of formula
R - Record RATE/Residuals in 20 minutes if tube feeding is running.

Front 6

TIGR OPEN, gloves soaked, clean gloves, PAT dry
SALAD

Back 6

Wound Management
T - Tape, put 4 strips of tape on the table and on the last one put your initials and date.
I - Inspect how the dressing is placed on. And do the tape the same way as it is.
G - Gloves: put on nonsterile gloves
R - Remove the old dressing, be careful not to drag the inner dressing along the skin. Remove dirty gloves.
OPEN: open all items that you will need (ABD pad, sterile gloves, NS bottle, gauze,etc)
GLOVES: put on non sterile gloves
SOAKED: With your non-dominant hand pour NS in to your packing gauze if a wet to dry dressing is required, if it is just a dry dressing then you don't need to do this. If you need to flush the wound , flush with normal saline.
CLEAN: Pick up a wet gauze with your other hand and wipe the inner wound (if orders to clean the wound)
GLOVES: Put on new sterile gloves.
P - Pack the Wound
A - ABD Pad on top
T - Tape

Record
S - Stage of wound
A - Appearance of wound
L - Location
A - Actions implemented an how pt tolerated.
D - Drainage sanguinous (bloody), serous (clear) serosanguinos (a mix of serous and sanguinous) Purulent?

Front 7

COCA RAT

Back 7

Drainage and Specimen Collection
C - Color of drainage
O - Odor of dranage/specimen
C - Consistency of drainage/specimen
A - Appearance of drainage/specimen
R - Record:
A - Amount of drainage/specimen
T - Type of drainage/specimen

Front 8

PVI RAT

Back 8

Irrigation
P - Position Pt
V - Verify placement of NG tube by first aspirating gastric contents AND then instill 200 cc air bolus
I - Instill fluid
R - Record:
A - Amount of solution used
T - Type of solution used.

Front 9

COMFORTERS

Back 9

Comfort Management must attempt 3 measures
C - Comfort measures do 3
O - Observe for discomfort
M - Meds PRN
F - Face wash
O - Oral Care
R - Relaxation
T - Treat with heat or cold
E - Evaluate comfort at end
S - Simple back rub

Front 10

Have I Drank Something

Back 10

Fluid Management
H - Hydration status - check skin turgor, mucous membranes, or anterior fontanel if child is < 1 Y.O. Must assess infant in upright position contraindicated.
I - I and O's
D - Drip rate: Must be recorded in the first 20 minutes
S - Site check: Is iv site warm, edema?

Must off pt fluids x1 if "Encourage Fluids"

Front 11

MAP HATR

Back 11

Musculoskeletal Management
M - Mobility Status: Full? Partial?
A - Abnormalities: With gait?
P - Pain with movement?

H - Heat or cold: If needed (apply for 20 mins unless otherwise indicated)
A - Apply devices (like knee braces) if needed
T - Traction: just make sure the lines are unobstructed, weight hangs free- if needed
R - Range of motion: The examiner will state if you have to do:
Passive or Active ROM
Upper or Lower Extermity or ies
One or both of the extremities

Front 12

MAD ATOP

Back 12

Mobility
M - Mobility status: Full? Partial?
A - Abnormalities with gait?
D Devices: Does the pt use a knew brace, walker, cane?

Ambulate
Turn Offload (pressure relief)
Position

Front 13

PAIR

Back 13

Respiratory Assessment
P - Position Pt
A - Assess the RRAP-Rhythm, rate, accessory muscle use, and pattern

Front 14

HAIR

Back 14

Respiratory Management
How did the pt tolerate deep breathing
Always perform assigned respiratory hygiene activity - deep breathing/cough OR
Incentive spirometry/suction/percussion
Reassess after deep breathing/cough/ICS (record how pt sounded before and after treatment)

Front 15

MARS

Back 15

Medication
Mar check and 5 rights
Allergies? Apical Pulse
Recheck MARS/KARDEX to pts ID BAND
Sign the MARS form

Front 16

ACCESS PRN

Back 16

PAIN
Assess: location duration and description
Pain scale 0-10/ faces/ FLACC tool
Reposition, relaxation Reminder to do something for the patient (comfort measure)
Need to reassess Pain go down, did intervention work

Front 17

3 P's, Look, Listen, Feel -DART

Back 17

Abdominal Assessment
Pee: Does pt need to pee before the exam
Pain: Does the pt have pain
Position: position should be flat with knees flexed, or as low as the pt can tolerate.
Look - at the abdomen
Listen - to the abdomen all 4 quads (on bare skin)
Feel - the abdomen (palpate) all 4 quads
D - Distended Abdomen
R - Rigidity
T -Tenderness

Front 18

RID

Back 18

PT Teaching
R - Readiness to learn: Mr smith is this a good time to talk about .....?
I - Identify learning needs: Mr Smith what do you know about ....?
D - Does the pt understand? Mr Smith what can you tell me about what we just talked about?