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21 Cards in this Set
- Front
- Back
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Comfort Management
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Comfort measures x3
Observe s/s discomfort or ask! Med (if assigned) Face Wash Oral Care Relaxation/Distraction Treat heat/cold Evaluate comfort Repo Simple back rub |
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Drain/Specimen
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Specimen collection
Place tube properly Examine COCA Clean with rx solution I and O RECORD Assess condition of site Label and send Color Odor Consistency Appearance/Amount |
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Wound Management
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Wound drainage Y or N
Observe Tail Unique irrigation and clean Need sterile field Dressing Implemented Type Appearance Infection Location |
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Enteral Feeding
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Rat
Amount Type Fowler Examine Tube/abdomen Verify Placement if Naso b&r Expiration? Strength? Rate- RECORD 20 MIN! |
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Abdominal Assessment
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Privacy?
Pee? Pain? Position? Look at abdomen? Listen-BS Feel-Palpate Does--Distention? Curt--Contour? Buy-BS Trucks-Tenderness? Really- Rigidity? **TURN SUCTION OFF |
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Skin Assessment
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Color
Integrity/Intact? Temperature Edema Y or N Moisture Y or N |
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Peripheral Vascular Assessment
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Pulses-->most distant
Motor--wiggle fingers/toes Sensation (tactile) Temp Cap refill Color |
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Irrigation
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Inspect tube placement
Right solution Repo pt for irrigation Instil air 10-20 Get receptecle Amount of irrigation fluid Temp (room temp) Irrigation return okay? Observe correct flow rate Naso (air/aspirate) |
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Pain Management
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Pain level
Character (dull/sharp) Location Duration **3 interventions** back rub relaxation/distraction hot/cold if assigned meds if assigned reposition |
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Neuro Assessment
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L- LOC, person,place,time
Assess fontanel (less than 1yr) Motor-hand grasps, dorsi/plant PERL noxious stimuli for non-reactive pt |
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Respiratory Assessment
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O2 saturation
Position Fowler's Assess RDA Instruct breath slow/deep Record- rythmn,depth,acccessory muscles BILATERALLY! |
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O2 Management
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Sat/Skin/Safety
O2 check, tubes, liters, humid Fowlers Tolerate activity, SOB? Even? Unlabored? Record nailbed Color Cap Refill Clubbing |
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Mobility
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Mobility Status
Abnormalities Devices Used? Do 1 Ambulate Turn Offload Position |
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Medication Administration
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Mar check
Allergies? Apical? Recheck Mar to ID Sign Mar |
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Respiratory Management
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O2 sat
Position Fowlers Assess RDA Instruct slow and deep Record RDA Have sit with kleenex Assess after C/DB Incentive Spirometer b4 C/DB Reassess |
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Musculoskeletal managment
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Mobility
Abnormalities Pain during movements? Heat or cold? Apply Devices Traction -weight -unobstructed weights -weight hang free -proper aligment -position counter ROM |
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Patient Teaching
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Readiness to learn
ID learning needs and give info Pt understanding |
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Fluid Management/20 min check
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Have(Hydration-tugor,MM)
I (I and O's) Drank (Driprate) Something (Site Check) |
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Safety
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Side rails
Call light within reach Adjust brakes Bed in LOW |
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REMINDER
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What(Wash hands)
I (ID pt) Ask (Ask comfort/pain) God (Glove, PRN) Daily (Do 20 min check) |
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Vitals
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BASELINE
Temp Pulse Resp Bp WEIGHT BEFORE BREAKFEST O2 Pain DECLARE!!! |
