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14 Cards in this Set

  • Front
  • Back
Mobility Level
Observe abnormalities
Balance-assist equipment
Increase support
Log patient's response
Evaluate overall safety
Mobility
Mobile
Hydration Status
Enteral fluids
Parenteral fluids/MAR/20min
Assess site
Tubing for air
Rate of fluids
Intake and Output
Notes all findings
Fluid Management
Hepatrin
BP, HR, RR, Temp, O2 sat, Weight, Pain- Adult Verbal 1-10, Child 3 or older 0-5 Faces, Child 2 months to 3 yrs FLACC, Non verbal signs in times pt unable to rate pain
Vital signs
Compare and get 2 sets
Position and Privacy
Suction off
Bowel and bladder distention
Examine first
Listen all 4 quadrants
Ligtly Palpate all 4 quadrants
Suction on and record
Abdominal Assessment
PS Bells
Level of consciousness
Assess fontanel while upright
Motor response of hands and feet and noxious stimuli
Pupil size and response to light
Neurological Assessment
Lamp
Pulses equal
Edema
Refill time
Inspect movement and sensation
Pale or pink
Hot or cold
Peripheral Neurovascular Assessment
Periph
Upright Position
Rate and Rhythm
Listen on skin
Auscultate Lungs sounds
Write down findings
Respiratory Assessment
Ur Law
Pain/Pink/Pale
Observe skin integrity
Warm/dry?
Do 2 areas on patient
Edema or moisture
Record/reposition
Skin Assessment
Powder
Conduct 3 comfort measures:
Observe for discomfort
Meds PRN
Face wash
Oral care
Reposition and relaxation
Treat with hot or cold
Even our bed sheets or change linen
Rub patient's back
See if comfort improved
Comfort Management
Comforters
Joint mobility
Observe abnormalities or pain
Implement ROM- abduct or flex
Needs heat or cold x 20 min
Therapeutic or supportive devices
Traction weight verified
Ropes hang free and unobstructed
Alignment correct
Countertraction provided and maintained
Musculoskeletal Management
Joint Trac
Activity tolerance
Inspect nail beds for color or cap refill
Reddened areas around nasal cannula
Assist pt to a better position for breathing
Look at O2 flow rate and adjust if needed
Set up humidification if needed
O2 sat monitor if needed
Oxygen Management
Air Also
Pain rating
Ask location, duration, and quality
Intervene x3
Now wait 20 min and reassess
Pain Management
Pain
Position patient
Listen to lungs
Examine pattern
Assist with interventions (C, DB, IS, CP, Suction)
Secretion cup at bedside
Evaluate and reassess
Respiratory Management
Please
Wash hands and glove up
Observe location, type, appearance, drainage
Use irrigation, clease, or pack when indicated
Now apply topical medicine
Dressing applied
Wound Management
Wound