CPNE

IWIPE

• Introduce self and examiner
• Wash Hands
• Id pt.
• Provide comfort and privacy
• Explain what im going to do

SCABS

• Siderails up (if ordered)
• Call light/phone in reach
• Ask about comfort lights/position
• Bed low and locked
• Skidproof foot wear

MOBILE

• Mobility status
• Observe for abnormalities
• Balance/ devices
• Implement tasks (ambulate, turn, reposition, offload)
• Log all
• Evaluate response

DISH

• Drip rate/type (enteral and parental, adjust if needed)
• I's and O's
• Site check (w/ gloves, check sites for edema, redness, drainage, dislodgement)
• Hydration status ( skin turgor, mucus membranes, or fontanel on child >1)

• 4PSLLF
• Privacy (shut door pull curtain)
• Pee?
• Pain?
• Position (supine elevate knees, unless contraindicated)
• Suction (suction off/ on when done assessing)
• Look (distention/discoloration)
• Listen ( X 4 for one min. sounds either present/absent)
• Feel (lightly palpate for mass, tenderness, rigidity)

• TIME C
• Temp (hot/cold/warm)
• Integrity (2 areas*, lesions/rash/pressure effects)
• Moisture (dry/perspiration/incontinence/intact ostomy)
• Edema (present or absent)
• Color (appropriate for ethnicity?)

*Areas= Heels, trochantor, sacrum/coccyx, occiput, skin folds)

BREATHE

• Breathing pattern (labored /unlabored)
• Rate/ Rhythm (regular/ irregular)
• Equipment, O2? (sats, room air?
• Accessory muscles/ assymetrical?
• Tell them to deep breathe
• Hear x 4 (top to bottom left to right) (clear/ abnormal)
• Evaluate response/record ( as a bilateral comparrison)

PERIPHS

• Pulses (check most distal for assigned extremity)
• Edema
• Refill (should be < 3 sec.)
• Inspect wiggle ( wiggle toes/ fingers)
• Pink/Pale
• Hot/Cold?
• Sensations (have them close their eyes and touch most distal part, have pt tell you which digit you're touching)

PEARLS

• Pupils PERL (equal, round and reactive to light)
• Equality of grasps/foot flex (plantar dorsi flex)
• Asses fontanel (in child >1)(upright)(soft,flat,depressed,bulging)
• Response to stimuli (apply pressure on nailbed)
• L. O. C. person, place, time or VAT*
• Symmetry AND movement (in child >3)

• *VAT (children 1-3yrs. and non communicating adults)
• Visual- response to familiar toy or object
• Auditory- response to name and sounds in room 
• Tactile-touch response to touching him/her

MARS

• MAR: Confirm 5 rights (pt.,dose,route,time,documentation)
• Allergies/Assessments*
• Recheck MAR with pt ID band (before giving med!)
• Sign MAR: Name,Date, ECSN

• *Digoxin-assess apical pulse follow hosp policy for holding
• *Morphine- ID time of last dose, assess pain level
• *Insulin-assess for hyper/hypoglycemia get most recent glucose level (use correct syringe for dose 100 or 50 unit)
• *Heparin/Lovenox-assess for bleeding, bruising all over body, do not aspirate, do not rub, dont expel air, apply pressure w/ 2x2 or new alcohol.
• *Cut pill with cutter if needed
• *G tube-crush well, add 30ml warm water to dissolve, flush with water before and after 15-30ml /adult, 5-10ml/ child)

• I SPECIAL
• ID pt. 1st!
• Specimine collect (in proper container)
• Place in proper place
• Examine COCA*
• Clean area(if assigned)(recod data!)
• I and O record
• Asses site and document condition
• Lable and send (date, time ,initials)

• *COCA
• Color 
• Odor
• Consistency
• Amount

RAT FEVER

• Record:
• Amount of formula AND
• Type of formula
• Fowlers position (HOB raised 45-60 degrees)
• Examine gastric tube ans abdomen
• Verifry placement (aspirate gastric contents, bolus 20ml air, listen)
• Expiration date or formula
• Record rate/ residual, reinstill residual

(burp baby)

• IRRIGATION
• Inspect for tube placement
• Right solution
• Repostion
• Instill in correct area
• Get receptacle
• Amount of irrigation fluid/ aspirate?
• Temp (room temp unless noted)
• Irrigation return okay?
• Observe flow rate
• Note solution used and amount

*Verify placement, instill 10-20ml air (5 for children >2) into stomach while listening, and aspirate for gastric contents.

LEARN

• Learning readiness
• Evaluate what they already know
• Act of learning
• Reassess what taught
• Note all of above

• -Ask ..Mr/Mrs_____ is it a good time to talk/teach you about_____?
• -Ask... What do you already know about ____?
• -After teaching....Can you tell me about what we just talked about?
• -Explain purpose and benefit or teaching.

WOUNDED

• Wound location/ type
• Observe appearance/drainage COCA*
• Unique irrigation,meds, supplies?
• Not sterile/ sterile dressing
• Dressing change
• Eval response/ pain
• Document all

• *COCA
• Color, Odor, Consistency, Amount

PAIN MAGMA 3

• Pain scale*(numerical adult,FACES >3,FLACC 2mo-3yr)
• Asses location, duration (constant/intermittent, long/often?)
• Intensity / description (sharp, dull,stabing, burning)
• Need to reassess in 20min.

• Massage/ Reposition
• Ask about measures to relieve
• Guide/ distract
• Medicate
• Apply heat/ cold
• 3 to do

*Observe behaviors (moaning, grimacing, clutching, restlessness)

MAD PART

• Mobilty status
• Abnormalities Atrophy?
• Devices/ Balance

• Pain
• Apply hot/cold
• ROM x 2 types (active/passive) abduct,adduct flex/extend
• Traction? (WWPUP)
• (record response)
• WWPUP
• Weight right,Weight hangs free, Proper alignment, Unobstructed weight, Position pt to provide counteraction

BREATHE EASIER

• Breathing pattern
• Rate/ Rythm
• Eval O2 status
• Accesory/ assemetry
• Tell them deep breathe
• Hear x 4
• Evaluate response

• Emesis basin / tissues
• Always DBC (deep breathe and cough)
• Spirometry if ordered (note if made goal)
• Implement assignments
• Evaluate response to them
• Reassess record before and after condition

SOAP

• Skin assessment (around cannula/mask ears/nares) red?intact?
• Oxygen check (O2 sats, refill,amount of O2, via? humidity?
• Activity tolerance (tired, SOB?)
• Position to help facilitate breathing

COMFORTERS 3

• Change environment
• Observe for discomforts
• Meds PRN
• Face wash
• Oral care
• Relaxation/Distraction
• Treat with heat or cold
• Evaluate when done and record response
• Reposition/ Change linens
• Simple back rub
• 3 of these to do