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21 Cards in this Set
- Front
- Back
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Enter Mneumonic
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Enter
Wash Intro Glove ID patient |
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Fluid Management
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Hydration 3 w-(PMS: p. fontanel, mucous m, skin Turg)
IV fluid verify Pump setting (or drops per minute) Palpate site (temp or edema) IV tubing Check enteral feeds (amt ingested /infused) Output (foley/other drainage) Write it on PCS form |
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Address the 4 Ps
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Privacy
Position Potty Pain (assist to br, check mobility, move to different position) |
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Mobility
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Mobility status/Use of Assistive devices
Observe abnormalities in balance ( if on bedrest, proper body alignment) Be there to help (place w/c on unaffected side) Increase support with external devices Log their response Evaluate |
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Safety
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Siderails up
Phone/Call light Everything OK? Low/Locked Bed Lights on/off Socks on |
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Skin Assessment
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Temperature
Wet/Dry Integrity Color Edema 2 areas (that are vulnerable based on condition) |
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Neurological Assessment
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Level x 3
Observe PERL Grips Inspect Fontanel (child) Check flex against resistance (dorsiflex BOTH feet simultaneously against Resistance) Symmetry/Movement (child) Stimulus ( if non responsive pt: first try verbal stimuli, if unsuccessful, try noxious stimuli by applying pressure to nail bed) |
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Respiratory Assessment
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Breathing Pattern
Rate/Rythmn Equip/Explain Auscultate Tell them to breathe deep Hear x 4 Eval Sats (if required) |
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Abdominal Assessment
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Privacy
Position (flat, knees bent) Pee? Pain? Suction Off Look Listen Feel Suction On |
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Peripheral Vascular Assessment
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Pulses
Edema Refill Inspect wiggle (<3yrs, Note movement 4 extremities) Pink/Pale Hot/Cold Sensations? (touch distal portions of extremity) |
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Pain Management
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Pain scale, location, Intensity/Description of pain
Assess behavior indicative of pain Intervention - 3 needed Need to reassess at 20 min 3 to do MGMTT Massage Guide/distract Medicate Turn them Temps (hot/cold app) |
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Musculoskeletal Management
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Movement (..how pt affected?)
Abnormalities (atrophy) Joint mobility Observe Pain with movement Range of motion AROM, PROM (supporting wt of extremity) Puts any supportive devices Applies heat/cold trt Right temp (and for 20 min at least) Traction (verifed wt used, ropes unobstructed, weights hang freely, pt positioned 4 counter traction, maintain pt in correct alignment) record all above on PCS |
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Respiratory Management
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Breathing Pattern
Rate/Rhythmn Equip/Explain Ascultate Tell them deep breaths Hear x 4 Eval response Emesis basin Assess readiness Suction (if assigned) IS or DBC Eval breath sounds Record effectiveness |
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Comfort Management
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Comfort needs of pt Psych/Phys/Environ
Observe s/s of discomfort Must do 3 measures Eval effect with a quote 3 interventions Reposition Dental hygiene Cold/Hot application Hygenic (face, hands) Arrange linens Narcs/Nsaids Comfort rub Environment adjustments Record it all |
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Oxygen Management
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Sats
Humidity Observe nares/ears Reposition up Tolerance to activity Amount of O2 Ignition sources Refill/Color/Clubbing |
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Wound Management
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W- TALK
I Cleanse Date/time/initial Wound (TALK- type, appearance, location, kind of drainage) Irrigation (if required STOP SPIL solution, temp, other basin, position, set up, placement check, instill slowly, look at return) Cleanse (asepsis) Date/time/initial/tolerance |
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Medications
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MAR check (Do the 5 rights), exp, calc, allergy?
R-record calc. on PCS I- Id patient S- shake NPH N- needle size Aspirate/ asepsis/ assess site if IV for edema, temp Pressure after IM Ensure to record within 30 min after giving |
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Patient Teaching
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Level of readiness
Evaluate pt knowledge Act of teaching Reassess and pt response Need to assess other learning needs |
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Specimen/Drainage
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Specimen collected
Place in container Ensure it is labeled Check COCA of speci/ transport (COCA= Color-Odor-Consis-Amt) Drainage amt, color, COCA Reposition for drainage Asepsis- clean surrounding skin Insert tube into app. cavity /maintain it. Need to flow by gravity |
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Irrigation
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Solution (Write amt of irrigating solution and kind)
Temp (room) Other equip need (basin,chux) Position for draining Set up Placement check (15 ml air adult, 5ml kids& ASPIRATE) Instill slowly Look at return |
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Enteral Feedings
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Solution - 5 rights, exp / calc. amt feeding
Temp (room) Orient patient / Position pt for feeding Measure placement Air NG tube 10-20ml OR 5ml <2 yrs Check residual/Aspirate for gastric contents/ RTn Have baby burp (0-6mths) |
