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22 Cards in this Set
- Front
- Back
Fluid Mgt
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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? |
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Musculoskeletal Mgt
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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. |
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Mobility
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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 |
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Respiratory Assessment
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PAIR
Position Pt Assess RRAP (Rhythm, Rate, Assessory muscle use, Pattern) Instruct to deep breath Record |
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Respiratory Mgt
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HAIR
How did Pt tolerate deep breathing? Always perform deep breathing and cough Incentive spirometry if assigned. Reassess after deep breathing/cough |
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Medication
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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 |
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PAIN
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PRN
Pain scale 0-10 Repositon- relaxation - do something for pain Need-to reassess pain level. |
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Abdominal Assessment
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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 |
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PT Teaching
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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? |
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Oxygen Mgt
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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. |
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Skin Assessment
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TIME Color
Temperature Integrity - Broken or intact? **Must assess 2 vulnerable skin areas. Moisture Edema Color |
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Peripheral Vascular Assessment
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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 |
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Neurological Assessment
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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. |
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Enteral Feeding
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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!! |
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Wound Management
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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 - |
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Drainage and Specimen Collection
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COCA RAT
Color - of drainage/specimen Odor - of drainage/specimen Consistency " " Appearance " " Record Amount Type |
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Irrigation
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PVI RAT
Position pt Verify solution and amount Instill fluid Record Amount Type of sulution used |
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Comfort Management
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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 |
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Respiratory Assessment
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PAIR
POSITION pt ASSESS the RRAP - (Rythm, rate accessary muscle use, and pattern) INSTRUCT to deep breath RECORD |
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IM/SQ Injection
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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 |
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IV MED STATION - PIGGY BACK
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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 |
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IV PUSH
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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 |