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28 Cards in this Set

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ABD ASSESSMENT

3P'S LLFMD
3 P'S- PEE, POSITION (SUPINE/KNEES BENT), & PAIN

L-LOOK (DISTENTION?)

L-LISTEN (START W/ RLQ MOVE UP)

F-FEEL (LIGHT PALPATION

M-MEASURE GIRTH (@ UMBILICUS/LYING FLAT)

DOCUMENT- SIZE, CONTOUR, BS, TENDERNESS OR RIGIDITY, AND GIRTH.
NEURO ASSESSMENT

LAPEN-R
L- Level of consciousness & orientation(PERSON, PLACE, TIME)

A- ASSESS ANT.FONTANEL IN CHILD <1 (upright postion, should feel flat/soft)

P- PUPILLARY RESPONSE-Dim lights and use pen light to check pupils response to direct light (NOTE: briskness/equality of pupil size bilat) Record PERRL.

E- EQUALITY OF MOTOR RESPONSES
(HAND SQUEEZE/FEET PUSH) **NOTE SYMMETRY/MOVEMENT IN CHILD 3 OR < OR NONCOMM. ADULT

N-NOXIOUS STIMULI= APPLY PRESSURE TO THE NAILBED.
*fOR PT NON-RESPONSIVE TO VERBAL STIMULI

RECORD-
*LOC/ORIENTATION
*FONTANEL
*PERRL
*EQUALITY OF MOTOR RESPONSE
*RESP TO NOXIOUS STIMULI (IF NECESSARY)
20 MIN CHECK

WIGCCED
W-WASH HANDS AFTER PLANNING PHASE

I-INTRODUCE SELF/CE AND ID PT X2

G-GLOVE UP

C-CHECK IV SITE (TEMP/EDEMA) AND HYDRATION STATUS (PINCH SKIN)

C-CHECK IVF FOR= RIGHT RATE? SOLUTION? TUBING FOR KINKS & AMT LTC. GLOVES OFF/GEL

E- EXPLAIN NEED TO COUNT I&0 AND RESTRICT/ENCOURAGE IF NEEDED. COUNT AMT OF FLUID AT START.

D-DOCUMENT W/IN 20 MINS OF START TIME
1.HYDRATION STATUS
2.IV SITE, APPEARANCE, IV RATE, & SOLUTION
SKIN ASSESSMENT

2-CTIMER
2-MINIMUM OF 2 VULNERABLE SKIN SURFACES TO ASSESS(SACRUM/COCCYX,HEELS,
FOLDS,OCCIPUT,TROCHANTER, PERIANAL,OR DESIGNATED AREA)

C-COLOR OF SKIN(PINK,PALE,NORMAL)

T-TEMPERATURE(WARM, COOL)

I-INTEGRITY(LESIONS, RASH, SHEER, TEARS)

M-MOISTURE(PERSPIRATION,INC)

E-EDEMA(PRESENCE/ABSENCE OF)

R-RECORDS THE ABOVE FINDINGS ON 2 VULNERABLE SKIN SURFACES.
PERIPHERAL VASCULAR ASSESSMENT

DP BILAT + CMST
(5 PS)
DP-Compare/Palpate distal pulses

C-check CRT/COLOR of ext. to assess PERFUSION

M-MOVEMENT of EXT or Child <3 or non-comm adult-OBSERVE MOVEMENT.

S-SENSITIVITY to TACTILE STIMULI (ask pt if he feels you touching his toes/fingers)

T-TEMPERATURE OF EXT (verbalize action to CE)

RECORD: ABSENCE/PRESENCE and EQUALITY of DP
CRT or COLOR
TEMP
RESPONSE to TACTILE STIMULI
MOTOR FXN
RESPIRATORY ASSESSMENT

PIAOM-R
P-POSITION(UPRIGHT OR SIDE-LYING IF UNABLE TO SIT UP)

I-INSTRUCT PT TO BREATHE IN & OUT DEEPLY

A- AUSC. BS OVER POST U/L LOBES USING SIDE TO SIDE METHOD.

O-OBSERVE BREATHING PATTERNS (RHYTHM, RATE, ACCESSORY MUSCLE USE)

M-MEASURE O2 SATS (IF ASSIGNES)

R-RECORD DATA R/T
COMP BS BIL(NORMAL/ABNORMAL)
ABNORMAL BREATHING PATTERNS
O2 SAT IF ASSIGNED
MOBILITY

A MAD
A-Assess pts LUB:
*LOM
*Use of assistive devices
*Balance abnormalites
(GAIT is steady/unsteady)

M-MOVES OR POSTIONS PT X1 IN PCS.
*SUPPORT, PROPER ALIGNMENT,
& USE OF SUPPORTIVE DEVICES

A-ASSISTS W/ TRANSFER OR AMBULATION
*MAINTAIN BALANCE
*USE STABILIZING EQUIP
*BARRIER/NON SKID FOOTWEAR

D-DOCUMENTS: AIR

LEVEL OF MOBILITY, ASSIST DEVICES USED, PRESENCE OF BALANCE ABNORM.

POSITIONING/TRANSFER/AMB ACTIVITES COMPLETED IN PCS.

PT RESPONSE TO THE ACTIVITIES
COMFORT MANAGEMENT

AI3RR
A-ASSESS COMFORT NEEDS (Ask & observe)

I-PROVIDE 3 COMFORT MEASURES (WASH, REPOSITIONS, MOUTHCARE, LINEN, BACKRUB, HEAT/COLD APP., RELAX/DISTRACT, ADM MEDS)

R-REASSESS COMFORT LEVEL

R- RECORD
1.INFO COLLECTED IN ASESSMENT OF COMFORT NEEDS
2. 3 COMFORT MEASURES IMPLEMENTED
3.PT RESPONSE TO THOSE (PT BEHAVIOR PRIOR/POST INTERV)
MS MANAGEMENT

J MASH T
A-ASSESS JOINT MOVEMENT OF AFFECTED AREA/EXT. FOR: (ABNORMALITIES, LOM, PAIN W/ MOVEMENT)

ENCOURAGE/ASSIST WITH:
1.AROM/PROM- ONE PAIR OF: ABDUCTION/ADDUCTION OR FLEXION/EXTENSION (SUPPORT JOINT ON PROM)
PROVIDE/APPLY:
2.DEVICES-SUPPORTIVE/THERAPEUTIC DEVICES
AND MAINTAIN SAFETY (SCDS, TEDS, CPM, IMMOB, BRACES/SPLINTS)

3.TRACTION MANAGEMENT (SKELETAL/SKIN)
VERIFY RX WEIGHT, ROPES UNOBSTRUCTED, WTS HANG FREELY,PT POSITION FOR ALIGNMENT/COUNTERTRACTION
DONT RAISE/LOWER HOB
2.APPY HEAT/COLD BY-PROTECT SKIN, APPLY TX AT RIGHT TEMP, MAINTAIN FOR 20 MINS

RECORD- (AIR) ASSESSMENT, MS MEASURES IMPLEMENTED, AND PTS RESPONSE TO MEASURES.
O2 MANAGEMENT

A OSPSHRD
A-ASSESS PTS RESPONSE TO ACTIVITY

0-CHECK O2 STATUS BY:
*INSPECT NAILBEDS FOR COLOR, CRT, OR CLUBBING
OR
*MEASURE O2 SATS

S- CHECK SKIN SURFACES IN CONTACT W/ 02 DEVICE(NARES, BEHIND EARS)

P-POSITION UPRIGHT TO FACILITATE BREATHING

S-SETS, ADJUST RATE, OR MAINTAINS O2 AT DESIGNATED FLOW RATE (LITERS/%)

H-HUMIDIFICATION MAINTAINED IF USED

R-REMOVE ARTICES THAT COULD SPARK/FLAME FROM BS AREA.

DOCUMENT-AIR
*RESPONSE TO ACTIVITY
*O2 STATUS
*SKIN CONDITIONS IN CONTACT W/ 02
*O2 MGNT MEASURES IMPLEMENTED
*PT RESPONSE TO INTERVENTIONS
PAIN MGT

AAPR AIR
ASSESS PAIN LEVEL-ASK/OBSERVE(FACES,SCALE, OR FLACC)

ADM PAIN MEDS/REPORT TO RN

PROVIDE PAIN RELIEF MEASURE X1-
REPOSITION, BACK RUB, RELAX/DISTRACT, HEAT/COLD APP

REASSESS PAIN LEVEL

DOCUMENT-PAIN LEVEL, PR MEASURES, PTS RESPONSE.
WOUND MANAGEMENT
WIAAMR
W-WOUND ASSESSMENT
TYPE/LOCATION/APPEARANCE/DRAINAGE/DRAINS/INFECTION S&S

I-IRRIGATE/CLEANSE WOUND W/ RX SOLUTION

A-APPLY OINTMENT AS ORDERED

A-APPLY NEW DRESSING, TAPE, LABEL W/ DATE/TIME/INITIAL

M-MAINTAIN ASEPSIS/WOUND PROTECTION

R-RECORD DATA R/T WOUND= LOCATION, TYPE, APPEARANCE, PRESENCE/ABSENCE OF DRAINAGE

MEASURES IMPLEMENTED TO CLEANSE/IRRIGATE/PROTECT WOUND AND SURROUNDING SKIN

PTS RESPONSE TO MEASURES IMPLEMENTED.
Critical Elements for Wound Management
The successful student
1. Complies with established guidelines related to managing a wound
2. Removes the dressing without contaminating the wound
3. Disposes of the dressing in the designated container
4. Prepares gauze for application to wound bed
5. Packs wound by applying moist dressing to wound bed
6. Applies a sterile dressing without contaminating the wound
7. Secures the dressing
8. Maintains asepsis
9. Labels the dressing with the date, time, and their initials
10. Completes all the Critical Elements within 15 minutes.
MUSCULOSKELETAL MANAGEMENT
M-MOBILITY STATUS –Pts ability to complete ADLs and amt of assistance needed

A- ABNORMALITIES- Presence/absences of abnorm (atrophy, contracture, flaccid, spastic)

P- PAIN W/ MOVEMENT- Note verbal expressions of discomfort or Ask pt about pain.

I- IMPLEMENT – Directs pt through AROM OR PROM for designated extremity by including one pair of the following:
ABDUCTION & ADDUCTION OR FLEXION & EXTEN SION
PROM- Support the weight of extremity at joints during ROM.

A- APPLIES supportive devices (splint, CPM, brace, TEDs, SCDs, & immobilizers)

HEAT/COLD when assigned (protect skin, right temp, maintain x 20min)

TRACTION- check wt, ropes hang freely, position pt. in correct alignment

R- RECORD- AIR
*Assessment findings: Abnormalities, LOM, & pain w/ movement and
*Measures implemented
*Pt Response to activity (dyspnea, nausea, fatigue, pain, dizzy)
PT TEACHING

RAIL PD RR
R- assess pts Readiness to learn (Ask ????)

A- Ability/Motivation to learn
*Is this a good time?
*Do you want more info on???

I-ID Barriers & specific
L- Learning Needs:
*DEVELOP TEACHING PLAN
*What does pt already know?
*Questions the pt has?
*What skills are needed?

P-PROVIDE INFO rt pts LEARNING NEED that is:

*SPECIFIC, ACCURATE, & BRIEF
*KISS-Keep is simple, safe,& specific

D-Determine Pts UNDERSTANDING of info taught.
*Feedback from pt/family
*Ask ? to encourage pt to explain what he learned.

R/R-Response & Record
*Asessment of Learning Readiness
*Information provided
*Pts RESPONSE to info provided
*EVIDENCE teaching was effective
EXIT/SAFETY CHECKS
P- Personal belongings in reach (Hearing aid, glasses & dentures)

C- Call light in reach

B- Bed lowest position/ Bed Brake

S- Siderails up

R- Remotes (tv, etc.)

P- Phone

R- Re-check the IVF rate or gtts/min

T- Total I&o

W- Wash hands
MEDICATIONS

WATCH MARS
W- Wash hands

A- Acquire meds
(using 5 rights) & Allergy / compatibility / expiration date checks

T- Take meds and MAR to room

C- Clean hands again

H- Have gloves (not required for PO meds unless at risk for contact with oral secretions)

M- MAR check to patient ID band (DOB,NAME,MR #)

A- Assess IV site (WITH GLOVES) again & other special parameters (apical pulse, B/P, lab results, etc.)

R- Re-check MAR with meds (and open at bedside if packaged unit doses)

S- Sign MAR: STAT after pt takes medications.

WASH HANDS!!!!
O2 MANAGEMENT

Air No Co2
A Always in Fowlers

I Inspect equipment/spark safety

R Record/regulate o2 rate

N Note humidity

O Observe skin surfaces(nose/ears)

C Color/clubbing/cap refill

0 O2 sats

2 Responses needed(before activity & after intervention)
ENTERAL FEEDINGS

ART Beats paying for time
Amt (up or ordered if bolus)
Right type, right device, right rate
Temp of ordered feeding
Burp if under 6 months
Position (check with air or residual)
Flush
Time +/- 30 minutes if bolus
Peripheral Vascular Assessment

PMS Causes Extreme Tension
**Compare the ext.bilat by:

Pulses-most DISTAL pulses (present/absent)

Motor- ask to move ext or OBSERVE ext movement in noncomm. adult/child <3 yrs.

Sensory stimulation-ask pt if they feel touch on toes/fingers

Color/Cap Refill- assess perfusion

Edema

Temperature- Warm/Cool

RECORD ALL r/t BILAT COMPARISION

**WASH AFTER YOU TOUCH PTS FEET
ENTERAL FEEDINGS (CONTINUOUS)

"FEED MY BELLY"
*FEED (DONE w/ 20 MIN CHECKS)
Make sure rate is accurate

You regulate flow rate if necessary and POSITION HOB >30 degrees.

Begin by verifying placement by: *Asp. gastric contents (ph 1-4=stomach contents) or *Instill 10-20cc of air while AUSC (5cc in child < 2 yrs)

Exact measurement of residual

Let me REINSTILL residual

Look at amt to be administered

YOU Record: name/strength/amt and record RESIDUAL,pH, & placement in NN (other)
Enteral Feeding (FOR ORAL)

"FEED ME"
Find right food and Position

Elect right device if needed

Encourage INFANT <6 mo to BURP

Deliver food at room temp.

Make sure to RECORD kind/amt

Evaluate tolerance
ENTERAL FEEDING (Intermittent)

"FEED MY HUNGER"
*FEED*

Measure amt to be administered

You calculate gtts/min


Hear air (instill 10-20cc)/aspirate gastric contents to verify placement

Usually measure RESIDUAL before feedings

Now REINSTILLS residual

Give feeding w/in 30 minutes of scheduled time

Either regulate rate by flow (gtts/min) or pump

Record name/strength/amt adminstered/pt tolerance
DRAINAGE & SPECIMEN COLLECTION
A-ASSES COLOR/AMT OF DRAINAGE

C-CLEAN SURROUNDING SKIN

SPECIMEN COLLECTION
O-OBTAIN NECCESSARY SPECIMEN
*urine, blood, stool,or wound drainage
*Using the Correct procedure in the CORRECT container

L-LABEL THE SPECIMEN

P-PLACES IT IN DESIGNATED ARE FOR TRANSPORT

R-RECORDS:
*data R/t Drainage AMT/COLOR

*data R/t Specimen collection
*what was collected, coca, pt tolerance, & where you took it
*doc. amt took in I &O section if assigned

A-ASSESS COCA FOR SPECIMEN COLLECTION:
*Color,Amt,Consistency& Odor)

C-CLEANS SURROUNDING SKIN
IRRIGATION
S-SELECT DESIGNATED SOLUTION

R-RIGHT TEMPERATURE

P-POSITIONS PT CORRECTLY

V-VERIFIES TUBE PLACEMENT (For NGT irrigation)

I-INSTILLS THE SOLUTION
* 5 RIGHTS (Irrigant, Amt, Temp, location)

C-CONTROL THE FLOW RATE
* NGT via gravity or enema <18 in. above rectum.

R-RECTAPLE POSTIONED FOR RETURN FLOW

RECORDS:
1.Kind of Irrigating solution
2.Amount
3.Pt response to if tx was effective or not
PV Assessment
MCTAPES
MCTAPES key Assessments for PVD:

Movement
Color, Condition, & CRT
Temperature
P-Absence/presence of pulses
Edema
Sensation
HEAT/COLD APPLICATION
PAT20 RR
P-PROTECTS THE SKIN SURFACE/BODY PART BEING TREATED

A-APPLY TX TO DESIGNATED BODY PART

T-TEMPERATURE SHOULD BE AS DESIGNATED

20-MAINTAINS TX FOR AT LEAST 20 MIN

RR-PT RESPONSE & RECORD FINDINGS
20 MINUTE CHECKS
1. Wash Hands

2. ID self & Patient (pt. X2)

3. Check Pump (IV or G-tube) rate & amount

4. Check hydration (turgor or fontanel)

5. Don gloves, Check IV site (temp/edema) toss gloves, wash hands

6. Explain I & O (restriction or adminitration orders)

7. RECORD...IV SITE APPEARANCE, RATE/Gtts, Turgor & I&O