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22 Cards in this Set
- Front
- Back
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Resp assess
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AIR SPLAM 0
Always position upright /listen side to side Instruct to breath x2 each steth placement Record splam s symmetry p pattern of breathing l lung sounds a acessory muslces used m movement o2 if assinged |
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abm assess
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ps bellys
pee first suction off bend knees keep flat examine abm. (flat, round,distention scars) listen x4 uads lightly palpate you mesure girth is assigned suction on |
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end things
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baash
bed low postion assist with call light assess comfort siderails up hands wash |
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20 min. checks
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wigaas
wah hands intro self and ce and Id pt gloves assess iv site record rate/advise I&O ask about pain comfort, air saftey and save tray |
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muscul mang.
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joint P
joint flexibity bilat observe strenght bilat(squeeze and flex) Implement ROM x3 note assistive devices treatment , traciton cas and hose pt response |
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personal cleanines
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clean
change linen lotion and skin prep examin and priviacy always chane wate x1 need oral care |
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mobility
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team BR
transfers extranous movement alignment/ aassistive devices movement balance response |
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pain mang.
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pain
pain acale assess location intervention x1 or med if assigned need to reassess |
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o2 mang.
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smoker
should be fowlers monitor (set) skin, equip, tubing observe 3r's rate, route, refill keep track pt response examine hazards record |
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fluid mang.
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Heparin
hydration status (tmf) turgor, membranes, fontaneal enteral feeding (kind) parental ( check and record) adjust flow rate rate of drops insertin site and I&O number on ICD |
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Resp mangt
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AIR SPLAM O AIR P
Always position upright /listen side to side Instruct to breath x2 each steth placement Record splam s symmetry p pattern of breathing l lung sounds a acessory muslces used m movement o2 if assinged APPLY RESP hygiene ( gtr) gloves.tissue receptable include reassessment record date in comparsion to first splam pt response |
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Periph vascu assess
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pulses bilat
examine crest c color r refill e edema s swelling t temp response to tiactile stimuli ( u touch pt eyes closed) movement wiggle toes and fingers |
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meds
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wow gipsis
Wash hands Obtain meds 5rights (tramp) 3 checks (sor) selecting, opening, returning Wash hands in room gloves Id pt x 2 forms prechecks site clean Id ptx2 , inject or give meds sign mars and wash hands |
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Neuro assess
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loc (ppt) person place time
observe perrl (dim lites) get speech response inspect fontneal or into noxious stimuli calculat strength of hands and feet(bilat) |
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skin assess
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A time CB
assess skin temp integrity moisture edema color braden scale |
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Vitals
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7
temp bp pulse resp o2 weight (use barriers) pain |
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comfort mang.
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APRR
Assess comfort level provide 3 measures reassess comfort level record response |
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pt teaching
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RIPPA
Ready to learn information pt knows pt teach pt response assess learning |
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enteral feeding
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feeding
feding type examine type/strength expiration date and temp don forgt hob 30 inspect placement and sie need rate recorded give feeding and burp babies |
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wound mang
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wound
wound drainage observe site, loction, type and condition unique irrigatin, topical and clean need sterile field prn and change drsg like before document initial , time and date pt response |
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Irrigation
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IRRG
inspect tue placment right supplies, loution and temp right position and flow rate get receptacle |
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Drainage/ specimen
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speical D
specimen collected place tube corectly examine coca ( color, odor, consistency amount) I&O Assess condition of site lael and send document all above |
