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36 Cards in this Set
- Front
- Back
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STOCKINGS |
Remove every 8 hours Hand-washed daily |
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Positioning |
Supine-- Recovering from surgery Prone-- on belly with roll or pillow under abdomen and feet Lateral-- one knee flexed in front of other Sims-- Both knees flexed one in front of other Orthopneic-- trouble breathing over a table Fowlers-- 45° after thoracic surgercardio problems Semi-Fowlers-- 30° nasogastric tube respiratory cardiac or neuro Trendel-- raise foot of bed Rev Trendel-- foot of bed goes down |
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Cane |
Hand on cane on unaffected side/siderail Cane on side of foot 6-12" in front Move affected leg forward Move unaffected leg in front of cane |
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Crutches |
Hold both on unaffected side 6" on side and 6" in front |
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AAPIE |
Assessment Analysis Planning Intervention/Implementation Evaluation |
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Assessment |
Observe Health History ASSESS |
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Observe |
Self-care Environment |
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Health History |
Underlying illness Cognitive Impairment Depression/mental |
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Assess |
Skin Feet Nails Oral Cavity Hair Eyes |
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Expected |
Clean with no odors Hair and facial hair groomed Nails clean/trimmed |
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Bathing |
Health promotion Social interaction Pleasure |
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Baths |
Assist Complete Partial |
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Special Considerations |
Dementia Obesity |
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Oral Care facilitates |
Removal of food Improved appetite Reduction pneumonia Condition of teeth Mouth |
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Ecchymosis |
Bruise |
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Erythema |
Skin inflammation/Flush |
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Pallor |
Anemia Circulatory |
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Jaundice |
Increase bilirubin |
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Skin Unexpected |
Velvety -thyroid disease Roughness - " or dehydration Diaphoresis- fever, thyroid disorder, increased activity |
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Unexpected-Lesions |
FLAT. RAISED Macule. Plaque Patch. Wheal RAISED SOLID Nodule Tumor Vehicle RAISED FLUID Bulla Pustules Cyst |
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ABCDE |
Asymmetry Border Color Diameter Evolving |
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Ulcer |
Pressure injury Poor blood flow Deeper depression |
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DEBRIS |
Crust- scab, eczema Scale- psoriasis, eczema |
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LICHTENIFICATION |
Chronic Skin inflammation Psoriasis |
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Pustule |
Acne Herpes |
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BULLA |
Blister Filled with serous fluid |
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TUMOR |
Raised from deeper in dermis Lippmann, neopl |
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NODULE |
Raised smaller than tumor Melanoma Hemagioma |
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Wheal |
Insect bite/ reaction Hives |
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Plaque |
Raised greater than 1cm Disc Psoriasis Eczema |
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MACULE |
Flat Freckles Mole Measles Scarlet fever |
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Patch |
Flat Birthmark Vitiligo Hormone changes |
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Papule |
Wart Elevated Elevated Mole Skin Tag |
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PALPATION |
Back of hands for findings |
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ISBARR |
Identify Situation circum req comm Background Assessment recent vit other Recomm Read Back order |
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NONMALEFICENCE |
Do No Harm |
