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32 Cards in this Set
- Front
- Back
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5 Phases of nursing process
ADPIE |
Assessment/Analyze, Diagnosis, Identification, Planning, Implementation. and Evaluation
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MASLOW's Hierarchy x 5
Plant Seeds of Love to Evaluate Self PSLES |
P: Physiology - O2, H2O, Sleep, Sex
S: Safety - resources, family, property L: Love/Belonging - friends/family E: Esteem, Self - respect, confidence S: Self Actualization - autonomy |
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Overiding areas of care x 5
CAMP |
Caring
Asepsis - Cleanliness Mobility Physical Jeopardy Emotional Jeopardy |
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Prior to beginning pt care
SHEEP |
S: Supplies - gather necessary eqp
H: Hygiene - wash hands E: Explain - procedure E: Expose - only necessary areas P: Proper temp - of environment/eqp |
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1st thing (Box 1)
EWIIG |
Enter
Wash Hands Introduce ID Gloves |
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20 min Check (Box 2)
HIPPICOW |
Hydration Status
IV (rate, amt, type) Palpate site (gloves) Pump (settings/drops) Inspect IV tubing check enteral feeds Oral fluid explain Write down findings |
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Required areas of care (x2) *
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Fluid Management
Vital Signs |
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Vital Signs (Box 3)
TPRBP-POW Compare |
Temp
Pulse Resp BP Weight O2 sat Pain Compare |
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Fluid Management
HIDS |
Hydration Check - Skin turgor/Mucous membrane
Intake/Output - measure all existing fluids Drip rate/pump setting Site check |
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Selected Areas of Care (x 16) **
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Abdominal Assessment
Neurological Assessment Perpheral Vascular Assessment PVA Respiratory Assessment Skin Assessment Comfort Management Musculoskeletal Management Oxygen Management Pain Management Respiratory Management Wound Management Drainage/Specimen Collection Enteral Feeding Irrigation Medications Patient Teaching |
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Selected areas of assessment x 5
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1) Abdominal Assessment
2) Neurological Assessment 3) Peripheral Vascular Assessment 4) Respiratory Assessment 5) Skin Assessment |
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Abdominal Assessment
4P's LLF RR |
P: Privacy
P: Potty P: Pain P: Position S: Suction Off L: Look - Distension L: Listen (need to hear sound x 1 min) F: Feel (if painful quadrant, complete last) R: Reposition R: Record |
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Neurological Assessment
LOGICSS |
L: Level of Consciousness
O: Observe Pupils - PERRL G: Grasps Hands bilateral/simultaneous I: Inspect Fontanel (while seated upright) C: Check dorsi flexion bilateral/simultaneous S: Stimuli (noxious) S: Symmetry and movement (child/non-com adult) |
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Respiratory Assessment
BREATHE |
Breathing pattern
Rhythm/Rate Explain procedure/get eqp (stethoscope/pillow/pulse ox if assigned) Auscultate (posteriorly/skin) Tell pt to breath slow/deep Hear - posteriorly on skin x 4 locations Evaluate/record |
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Peripheral Vascular Assessment
PERIPH |
Pulses - most distal bilateral extremities (pedal/radial)
Edema Refill (capillary) Inspect sensation/movement OR noting extremity movement (<3 yrs) Pale/Pink Hot/Cold - temperature |
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Skin Assessment
SKINNED |
Skin Color
Keep warm and dry Integrity/intact Note edema Need re-positioning Evaluate pain Do two areas |
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Skin Assessment (two areas to assess)
A SHEETS |
Anal
Skin folds Head Ears Elbows Trochanters Sacral/Coccygeal |
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Areas of Management x 6
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1) Comfort Management
2) Musculoskeletal Management 3) Oxygen Management 4) Pain Management 5) Respiratory Management 6) Wound Management |
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Comfort Management
A 3rd CHANCERR |
Assess comfort level
3 comfort measures Reposition Dental Hygiene Cold/Heat Hygiene (face/hands) Arrange Linens NSAIDS, Narcotics Comfort rub Environmental adjustments Relaxation/Distraction techniques Record (evaluation, measures,re-eval) |
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Musculoskeletal Management:
MAD PART |
M: Mobility status
A: Abnormalities D: Devices/Balance P: Pain with Movement A: Apply Hot or Cold (use barrier x 20 min) R: ROM (Active/Passive - Abduction/Adduction or Flexion/Extenson) T: Traction |
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Oxygen Management
BREATHE |
Best Position (Semi-Fowlers or higher)
Response to Activity Ears and Nares (whatever skin contacts NC/Mask) Assess nailbed color, cap re-fill, clubbing OR SpO2 (if assigned) Triggers to combustion Humidity Ensure O2 device is applied/designated rate |
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Respiratory Management
BREATHE EASIER |
Breathing pattern
Reposition if needed (Semi-Fowlers or higher) Explain procedure/get eqp (stethoscope/pillow/pulse ox if assigned) Assess deep breathing/accessory muscles/rhythm/rate Tell pt to breath slow/deep Hear - posteriorly on skin x 4 locations Evaluate O2 (if assigned) Emesis basin Assess breathing Suction no more than 15 sec after insertion (if assigned) Incentive or DB & C Evaluate Record |
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Pain Management
PAIN MGMTT |
Pain scale (FLACC, Faces, 0-10)
Assess location of pain Identify - quality/characteristics/duration of pain Need to reassess 20-30 min after implementation Massage Guide/distract Medication (if assigned) Turn (reposition) Temp - heat/cold (if assigned) **pick 3 of the MGMTT to do |
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Wound Management
WOUNDED |
Wound location
Observe drainage (appearance/type/amount) Understand process - eqp/solution/temp/position/protect skin Need clean or sterile field? Dressing change Evaluate pain tolerance Document what you did, findings, and tolerance |
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Additional areas of care (AOC) x 5
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1) Drainage/Specimen Collection
2) Enteral Feeding 3) Irrigation 4) Medications 5) Patient Teaching |
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Drainage/Specimen Collection
I SPECIAL |
ID Patient before
Specimen collected Place tube properly Examine color, odor, consistency, amount (coca) Clean surrounding skin (if ordered) I & O recorded for drains (if assigned or dc'd) Assess patency of tubes Label and send specimen (if ordered) |
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Enteral Feeding
FEEDING |
Feed (NG, GT, bottle,etc)
Examine name/strength and rate Expiration date check Do bed at 30 degrees Inspect/Aspirate of tube (10 ml adult/ 5 ml <2 yrs air bolus/auscultate/aspirate gastric content) Need to measure content and document feeding (rate in during 20 min check) Give feed and burp if <6 months old |
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Irrigation
IRRIGA P |
Inspect/verify tube placement
Right solution & temp Reposition patient Instill at correct flow rate/force Good return flow ensured Amount/solution used recorded Patient response to tx. |
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Medications
MAR DOSES |
Mar check meds
Appropriate dose Recheck MAR to ID Do 5 R's Observe Allergies Special Assessment (BP, pulse) Equipment Sign MAR |
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Patient Teaching
LEARN |
Level of readiness/motivation OR barriers to learning
Eval pt knowledge/needs Act of teaching (5 min) Reassess pt. understanding Need pt response to information taught |
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Safety (Last Grid Box)
SCABS |
S: Side rails up
C: Call light/phone within reach A: Ask is there anything else? B: Bed low/locked S: Socks |
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Mobility
MOBILE |
Movements
Observe alignment Balance/Devices Increase support Log response Evaluate |
