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. What would you like to do?
- Introduce self and examiner
- Wash Hands
- Id pt.
- Provide comfort and privacy
- Explain what im going to do
- Siderails up (if ordered)
- Call light/phone in reach
- Ask about comfort lights/position
- Bed low and locked
- Skidproof foot wear
- Observe for abnormalities
- Balance/ devices
- Implement tasks (ambulate, turn, reposition, offload)
- Log all
- Evaluate response
- 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)
- Privacy (shut door pull curtain)
- 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)
reathing 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)
PERIPHERAL VASCULAR ASSESSMENT
- Pulses (check most distal for assigned extremity)
- Refill (should be < 3 sec.)
- Inspect wiggle ( wiggle toes/ fingers)
- Sensations (have them close their eyes and touch most distal part, have pt tell you which digit you're touching)
- 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
AR: Confirm 5 rights (pt.,dose,route,time,documentation)
- 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)
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)
- 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
- Inspect for tube placement
- Right solution
- 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.
- 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.
- Wound location/ type
- Observe appearance/drainage COCA*
- Unique irrigation,meds, supplies?
- Not sterile/ sterile dressing
- Dressing change
- Eval response/ pain
- Document all
- 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
- Apply heat/ cold
- 3 to do
*Observe behaviors (moaning, grimacing, clutching, restlessness)
- Mobilty status
- Abnormalities Atrophy?
- Devices/ Balance
- Apply hot/cold
- ROM x 2 types (active/passive) abduct,adduct flex/extend
- Traction? (WWPUP)
- (record response)
- Weight right,Weight hangs free, Proper alignment, Unobstructed weight, Position pt to provide counteraction
- 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
kin 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
- Observe for discomforts
- Meds PRN
- Face wash
- Oral care
- 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?
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