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Oxygen Management
- SOAP
- Skin Assessement: check skin around canula, face mask. Is intact? Red?
- Oxygen check: 02 sats, or cap refill
- Activity: assess pts' response to activity. Tired? SOB?
- Position: position to help facilitate breathing
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Pain
PRN
- Pain: assess pain using appropriate scale
- Reminder: reposition, relaxation (do something for pt's pain)
- Need to reassess: once more, remember to document pain level before intervention (intervention, response, pain after)
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Patient Teaching
RID of ignorance
- Ready to learn: is pt ready/willing to learn. "Mr. Smith, is this a good time to talk about ______?"
- Identify learning needs: note what pt teaching is assigned with. "Mr. Smith, what do you know about ______?"
- Did pt understand: Provide evidence such as pt statement that indicates pt understood. "Mr. Smith, can we tell you what we just talked about?"
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Abdominal Assessment
4P'S - Look, Listen, Feel
- Privacy: Be sure to shut door and pull curtain
- Pee: ask pt is they have to pee.
- Pain: ask pt if they are experiencing any adb pain.
- Position: if there are no inhibiting factors (pain, limited ROM, resp concerns) place pt in as supine a position as poss and elevate knees.
- Suction: turn suction off, and remember to turn on at end
- Look: note any distention, discoloration
- Listen: auscultate 4 quadrants for bowel sounds. Listen for a full minute before declaring bowel sounds absent.
- Feel: palpate 4 quadrants, assessing for pain, tenderness, rigidity.
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Neuro Assessment
LAMP
- LOC: person, place, time. (document)
- Assess Fontanel: pt less than 1 yr. Must sit child up to perform assessment. Document flat, depressed, or bulging.
- Movement: ask pt to elevate arms while gripping index and middle fingers with hands. Lower ext- do plantarflex or dorsiflex.
- PERRL: (CE will have penlight) Dim lights and place one hand along nose vertically to shield. Assess equality, roundness, reactivity. Document bilateral comparison.
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Peripheral Vascular Assessment
Please Make Sure To Check Cap Refill
- Pulses: check most distal pulses for assigned extremity.
- Movement: assess movement of most distal portion of assigned extrem. Ask to wiggle toes, fingers, stumps, etc.
- Sensation: ask pt to close eyes. Lightly touch most distal portion of assigned extremity. Ask pt to tell you which digits you are touching.
- Temperature: assess temp of distal portion of assigned extremity and document as warm, hot, cold.
- Color or Cap Refill: only one is required.
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Respiratory Assessment
O'PAIR
- Oxygen Saturation: if assigned.
- Position: assist pt into a position to facilitate assessment. (sitting or on side)
- Assess RRAP: rhythm, rate, accessory muscle use, pattern. Breath sounds (document as clear or abnormal). Watch rise and fall of chest for assym movement. Listen to top lobes first, then bottom.
- Instruct pt to breathe as deeply as possible while assessing.
- Record data...make sure it is structured as bilateral comparison.
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Respiratory Management
O'PAIR HAIR
Oxygen Saturation: if assigned. - Position: assist pt into a position to facilitate assessment. (sitting or on side)
- Assess rhythm, accessory muscle use, pattern (RAP), breath sounds (document as clear orabnormal). Watch rise and fall of chest for assymetrical movement. Listen to top then bottom.
- Instruct pt to breathe as deeply as possible while assessing.
- Record data...make sure it is structured as bilateral comparison.
- How did pt tolerate deep breathing and cough
- Always perform deep breathing and coughing exercise.
- Incentive spirometer, if assigned.
- Reassess/record -status of resp conditions prior to and after interventions compared. Must be documented, as well as pt's response to interventions.
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Skin Assessment
TIME to check Color of Skin
- Temperature: assess temp of pt's skin
- Integrity: assess integrity of pt's skin. (lesions, rashes, sheer, pressure effects, skin tears) 2 areas (occiput, trochantar, heels, sacrum)
- Moisture: abnormal moisture (perspiration, incontinence, diarrhea, non-intact ostomy/drainage system)
- Edema: documented only as present or absent
- Color: assess color of skin. If normal document as "skin color appropriate for ethnicity."
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Medication
MARS & 5 rights
- MAR: confirm 5 rights (pt, med, dose, route, time)
- Allergies: Also apical pulse - if required
- Recheck MAR to pt ID band immediately before administering meds
- Sign the MAR: name, initial, ECSN
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Musculoskeletal Management
MAP HATR
- Mobility status: ssess mobility of designated extremities.
- Abnormalities: note any abnormalities, atrophy, etc that are related to designated extremities.
- Pain: ask pt is they are experiencing any pain or increased pain with movement of designated extremities.
- Hot or Cold pack, if assigned
- Apply/adjust devices
- Traction
- ROM exercises
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Mobility
MAD ATOP
- Mobility status
- Abnormalities
- Devices: does pt use knee brace, walker, cane?
- Ambulate
- Turn
- Offload
- Position
(Must do one of last 4..ambulate, turn, offload, position)
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Fluid Management
Have I Drank Something?
- Hydration status
- I and O's
- Drip rate
- Site check
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Enteral Feeding
RAT FEVER
- Record:
- Amout of formula AND
- Type of formula
- Fowlers: position in Fowlers to receive tube feeding
- Examine gastric tube/abd
- Verify placement: verify G tube by aspirating gastric contents OR instilling 20 cc air bolus and listening.
- Expiration date of formula
- Record rate in 20 Minute drill: a pt that has running tube feeding IS part of 20 min drill
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Safety
- SCABS
- Side rails up x 3
- Call Light/phone
- Ask if can do anything
- Bed in locked/low position
- Skid proof socks
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Comfort Management
COMFORT ERS (Attempt 3)
- Comfort: do 3
- Observe for discomfort
- Meds PRN
- Face wash
- Oral care
- Relaxation
- Treat with heat/cold
- Evaluate comfort at end
- Reposition
- Simple back rub
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