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30 Cards in this Set
- Front
- Back
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ADPIE (nursing process) |
assessment, diagnosis, planning, interventions, evaluation |
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NANDA |
north american nursing diagnosis association |
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NOC |
nursing outcome classification |
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NIC |
nursing interventions classification |
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NCP |
nursing care plan |
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PES |
problem, etiology, symptoms (actual, nursing diagnosis format) |
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R/T |
related to |
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AMB |
as manifested by |
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FDAR (charting) |
Focus, Data, Action, Response |
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SBAR (communication) |
situation, backround, assessment, recommendation/rationale/ratify |
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CGWIPE (skills resource manual checklist) |
check order/ allergies, gather supplies, wash hands, ID client and self, prepare, and explain procedure |
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MAR |
Medication Administration Record |
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HTT |
Head-to-Toe Assessment |
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PERRLA |
Pupils Equal Round and Reactive to light and Accommodation |
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PPOSSCcS (Lymph Nodes-HTT) |
Preauricular, Posterior Auricular, Occipital, Submental, Submandibular, Cervical chain, Supraclavicular |
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CMITT (Integument part of Head-to-Toe Assessment) |
Skin Color, Moisture, Intact, Temperature, Texture |
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APTM (Auscultation regions for cardiac assessment-HTT) |
Aortic, Pulmonic, Tricuspid, Mitral |
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RRED (Respiratory assessment- HTT) |
Rate, Rhythm, Effort, Depth |
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RAS (Peripheral Pulse Assessment - HTT) |
Rythm, Amplitude, Symmetry |
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CRT |
Capillary Refill Time |
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CMST |
Color, Motion, Sensation, Temperature |
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CSP (Abdominal Inspection- HTT) |
Contour, Symmetry, Pulsations |
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REEDA (wound assessment) |
Redness, Edema, Ecchymosis, Drainage, Approximation
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COCA (wound drainage) |
Color, Odor, Consistency, Amount |
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MSBITES (assessment of skin prior to sub-q / IM injection |
Masses, Scaring, Bruising, Inflammation, Tenderness, Edema, Site |
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ABCD (skin lesions) |
Asymmetry, Border, Color, Diameter |
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PQRSTU (pain assessment) |
Provoked, quality, region/radiation, severity, timing, understanding |
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ABCDE (pain assessment) |
ask about pain regularly believe the reported pain. Choose appropriate Pain control options. Deliver interventions in a timely, logical and coordinated order. Empower patient to control their course for best outcome |
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SATA |
Select all that Apply |
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DOPE (Airway) |
Displacement, Obstruction, Pneumothorax, Equipment |
