Cpne Jt

Front 1

Fluid Mgt

Back 1

HIDS -Have I Drank Something?

HYDRATION status- (skin turgor)

I and O's

DRIP RATE - Record during 1st 20 minutes.
SITE CHECK - Is IV site warm? Edema present?

Front 2

Musculoskeletal Mgt

Back 2

MAP HATR

Mobility Status -Full?Partial?
Abnormalities - with gait?
Pain with movement?

Heat or cold - if needed
Apply devices (ex. knee brace) is needed
Traction - weights hang free?
Range of Motion - The examiner will specify passive or active ROM.

Front 3

Mobility

Back 3

MAD ATOP

Mobility status - Full?Partial?
Abnormalities with gait?
Devices -Does Pt use walker or cane etc?

MUST Ambulate, Turn, Offload or Reposition during PCS.
Ambulate
Turn
Offload
Position

Front 4

Respiratory Assessment

Back 4

PAIR

Position Pt
Assess RRAP (Rhythm, Rate, Assessory muscle use, Pattern)
Instruct to deep breath
Record

Front 5

Respiratory Mgt

Back 5

HAIR

How did Pt tolerate deep breathing?
Always perform deep breathing and cough
Incentive spirometry if assigned.
Reassess after deep breathing/cough

Front 6

Medication

Back 6

MARS

Mar check and 5 rights
Allergies? Apical Pulse check?
Recheck MARS/KARDEX to pts ID BAND - Do when in the pts room with the meds.
Sign the MARS form

Front 7

PAIN

Back 7

PRN

Pain scale 0-10
Repositon- relaxation - do something for pain
Need-to reassess pain level.

Front 8

Abdominal Assessment

Back 8

PPP Look Listen and Feel

Pee? Does Pt need to Pee prior to exam?
Pain? Does Pt have pain?
Position - Pt flat with knees flexed or as low as tolerated.
Look at abdoment
Listen to 4 quadrants
Feel all 4 quadrants

Front 9

PT Teaching

Back 9

RID

Readiness to learn - Mr Patient is this a good time to talk about______?
Identify Learning Needs - Mr
Patient what do you know about_____?
Does Pt understand? Mr Patient, what can you tell me about what we talked about?

Front 10

Oxygen Mgt

Back 10

SOAP

Skin Assessment- check skin around cannula, fase mask, ears...intact?, Red?
Oxygen Status- O2 sats OR cap refill.
Activity Level - assess pts response to activity. Tired? SOB?
Position? - Position Pt to help facilitate breathing.

Front 11

Skin Assessment

Back 11

TIME Color

Temperature
Integrity - Broken or intact?
**Must assess 2 vulnerable skin areas.
Moisture
Edema
Color

Front 12

Peripheral Vascular Assessment

Back 12

Please Make Sure To Check Cap Refill

Pulses present? Find most distal pulses
Movement - Ask Pt to move extremeties --note movement in child <3.
Sensation - Did Pt feel me squeeze hand or foot?
Temperature
Color
Capillary Refill

Front 13

Neurological Assessment

Back 13

LAMP

LOC - Person place time
Assess fontanelle - in <1 flat?bulging?depressed?
Movement- hand grasp/pushdown and up AND pedal push/pull
PERRLA - Pupils equal, round reactive to light and accomadation.

Front 14

Enteral Feeding

Back 14

RAT FEVER

Record
Amount of formula AND
Type of formula

Fowlers Position in fowlers to receive tube feeding.
Examine- gastric tube/abdomen
Verify Placement - Verify G tube placement by aspirating gastric contents.......and instilling 20 cc air bolus and listening (must do both)
Expiration Date- of formula
RECORD RATE IN 20 MINUTES.....REMEMBER - Pts with running tube feedings are part of my 20 minute checks!!

Front 15

Wound Management

Back 15

TIGR OPEN, gloves soaked, clean gloves, PAT dry.

TAPE - 4 strips of tape on table putting initials time/date on last strip.
INSPECT - How is dressing placed....tape and place ABD pad same way.
GLOVES - Don nonsterile gloves.
REMOVE old dressing....pull gloves over soiled dressing and discard.
OPEN - Open all items
GLOVES - Put on sterile gloves if needed.
SOAKED with nondominant hand pour NS into tub of gauze if wet to dry dressing is required. If just a dry dressing then don't need to do this. If tasked with flushing the wound with NS or some other fluid this is the time to SOAK the wound.
CLEAN- pick up wet gauze with othe hand and wipe inner wound (if orders are to clean the wound.
GLOVES - Don new sterile gloves because you just touched a nonsterile bottle of NS to pour into gauze.

PACK wound
ABD pad on top
TAPE

Record what was done using SALAD
STAGE wound ex Pressure Ulcer stage I, II, III, IV? Surgical wound? etc.
APPEARANCE of wound
LOCATION of wound
ACTIONS Implemented ex...Surgical wound dressing removed. No complaints of pain or discomfort during treatment.
DRAINAGE sanguinous (bloody) Serous (clear) serous sanguinous (mix of both) Purulent? Puss y?
CLEAN -

Front 16

Drainage and Specimen Collection

Back 16

COCA RAT

Color - of drainage/specimen
Odor - of drainage/specimen
Consistency " "
Appearance " "

Record
Amount
Type

Front 17

Irrigation

Back 17

PVI RAT

Position pt
Verify solution and amount
Instill fluid

Record
Amount
Type of sulution used

Front 18

Comfort Management

Back 18

Must attempt 3 comfort measures

Comfort measures - do 3
Observe for discomfort
Meds PRN
Face wash
Oral care
Relaxation
Treat with hot or cold
Evaluate comfort at end
Reposition
Simple back rub

Front 19

Respiratory Assessment

Back 19

PAIR

POSITION pt
ASSESS the RRAP - (Rythm, rate accessary muscle use, and pattern)
INSTRUCT to deep breath
RECORD

Front 20

IM/SQ Injection

Back 20

RCAD RIG CAP

Roll - If NPH insulin roll bottle to mix

Clean - vials with alcohol

Air - Inject air into vials - Keep bottles on table with injecting air.

Draw up med

Recap needle (scoop method)

I.D. pt before I give med.

Glove up

Clean site

Aspirate
for IM only, not needed for Insulin, Heparin or Lovenox (if lovenox assigned during PCS-don't expel air bubble)

Pressure

Front 21

IV MED STATION - PIGGY BACK

Back 21

I Glove I Glove CDS AO

ID patient

GLOVE - put on non sterile gloves

INSPECT IV site - verbalize, "no edema"

GLOVES off for comfort

CLAMP both tubing

DROP Primary

SPIKE med bag

AIR present in tubing? Champagne bubbles OK. Fix big gaps.

OPEN secondary med an start to count drips

SIGN MAR

Front 22

IV PUSH

Back 22

CLEAN, LABEL, CLEAN, FIGIWA FLUSH GIVE FLUSH

CLEAN top of med bottle to be used

LABEL label 3 empty syringes by wrapping tape around them and putting NS on the first 2, then nameof the med on the last

CLEAN clean NS port on bag before drawing up flushes

FIGIWA

FLUSHES draw up the 2 flushes with the amount the amount stated in the MAR

ID pt

GLOVE up with nonsterile gloves

INSPECT IV site - verbalize no edema

WIPE IV port with alcohol (the IV will be attached to a mannequin arm)

ASPIRATE

FLUSH flush IV site with NS.

GIVE give the med over 30 seconds or 2 minutes or whatever the MAR says.

FLUSH flush IV again