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14 Cards in this Set
- Front
- Back
Mobility Level
Observe abnormalities Balance-assist equipment Increase support Log patient's response Evaluate overall safety |
Mobility
Mobile |
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Hydration Status
Enteral fluids Parenteral fluids/MAR/20min Assess site Tubing for air Rate of fluids Intake and Output Notes all findings |
Fluid Management
Hepatrin |
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BP, HR, RR, Temp, O2 sat, Weight, Pain- Adult Verbal 1-10, Child 3 or older 0-5 Faces, Child 2 months to 3 yrs FLACC, Non verbal signs in times pt unable to rate pain
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Vital signs
Compare and get 2 sets |
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Position and Privacy
Suction off Bowel and bladder distention Examine first Listen all 4 quadrants Ligtly Palpate all 4 quadrants Suction on and record |
Abdominal Assessment
PS Bells |
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Level of consciousness
Assess fontanel while upright Motor response of hands and feet and noxious stimuli Pupil size and response to light |
Neurological Assessment
Lamp |
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Pulses equal
Edema Refill time Inspect movement and sensation Pale or pink Hot or cold |
Peripheral Neurovascular Assessment
Periph |
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Upright Position
Rate and Rhythm Listen on skin Auscultate Lungs sounds Write down findings |
Respiratory Assessment
Ur Law |
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Pain/Pink/Pale
Observe skin integrity Warm/dry? Do 2 areas on patient Edema or moisture Record/reposition |
Skin Assessment
Powder |
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Conduct 3 comfort measures:
Observe for discomfort Meds PRN Face wash Oral care Reposition and relaxation Treat with hot or cold Even our bed sheets or change linen Rub patient's back See if comfort improved |
Comfort Management
Comforters |
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Joint mobility
Observe abnormalities or pain Implement ROM- abduct or flex Needs heat or cold x 20 min Therapeutic or supportive devices Traction weight verified Ropes hang free and unobstructed Alignment correct Countertraction provided and maintained |
Musculoskeletal Management
Joint Trac |
|
Activity tolerance
Inspect nail beds for color or cap refill Reddened areas around nasal cannula Assist pt to a better position for breathing Look at O2 flow rate and adjust if needed Set up humidification if needed O2 sat monitor if needed |
Oxygen Management
Air Also |
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Pain rating
Ask location, duration, and quality Intervene x3 Now wait 20 min and reassess |
Pain Management
Pain |
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Position patient
Listen to lungs Examine pattern Assist with interventions (C, DB, IS, CP, Suction) Secretion cup at bedside Evaluate and reassess |
Respiratory Management
Please |
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Wash hands and glove up
Observe location, type, appearance, drainage Use irrigation, clease, or pack when indicated Now apply topical medicine Dressing applied |
Wound Management
Wound |