CPNE

Card Set Information

Author:
kaumae
ID:
179731
Filename:
CPNE
Updated:
2012-10-24 23:01:48
Tags:
CPNE
Folders:

Description:
Mneumonics
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user kaumae on FreezingBlue Flashcards. What would you like to do?


  1. Entering Room
    IWIPE

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

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

    • Mobility status
    • Observe for abnormalities
    • Balance/ devices
    • Implement tasks (ambulate, turn, reposition, offload)
    • Log all
    • Evaluate response
  4. FLUID MANAGEMENT
    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)
  5. ABDONMINAL ASSESMENT
    • 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)
  6. SKIN ASSESSMENT
    • 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)
  7. RESPIRATORY ASSESSMENT
    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)
  8. PERIPHERAL VASCULAR ASSESSMENT
    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)
  9. NEUROLOGICAL ASSESSMENT
    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
  10. MEDICATIONS
    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)
  11. DRAINAGE AND SPECIMEN COLLECTION
    • 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
  12. ENTERAL FEEDING
    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)
  13. IRRIGATION
    • 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.
  14. PATIENT TEACHING
    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.
  15. WOUND MANAGEMENT
    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
  16. PAIN MANAGEMENT
    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)
  17. MUSCULOSKELETAL MANAGEMENT
    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
  18. RESPIRATORY MANAGEMENT
    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
  19. OXYGEN MANAGEMENT
    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
  20. COMFORT MANAGEMENT
    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

What would you like to do?

Home > Flashcards > Print Preview