Enter Wash Intro ID Need? (Caring) Comfort/sleep well?

20 Minute Checks W=wash, I=ID, P=privacy MEDs MARMedExpiration Appropriate Dose Recheck MAR w/ ID Do 5 rights Observe allergies Special Assessments (b/p, pulse, bruising, bleeding pain level) Ask how takes? Gather supplies Evaluate/administer Sign MAR RESP Assessment Position Rhythm/rate/pattern Equipment Ascultate bilaterally Tell pt breath deep/slow Hear ABN/NORM O2 Sat WIP WIP

Fluid Management Hydration Enteral (offer if encourage fluid)

WIP

V/S T (O, ax, temporal, tympanic) P (radial, apical) R B/P (manual, automatic) Wt (balance scale, barrier, undress, Prior to eating/feeding) O2 sat Pain level (SHOW CE) WIP NEURO Assessment Consciousness x 3 (or observe/stimulate) Anterior Fontanel (if app) PERL Equality Stimuli WIP

Mobility ABN balance

WIP

Moves (equally, freely, no difficulty) Devices (walker, abductor pillow) Ambulate/Align Transfer/turn/lift Position w/ support Observe gait/balance Pt response Safety (Stabilize equipment, footwear) PVA Palpate pulses Compare bilaterally Perfusion (color or cap RF) Temperature Tactile stimulation Motor movement WIP

Parenteral w/ Kardex (fluid,rate,tubes) Assess site w/ gloves Regulate rate Record fluids infusing (note volume) I&O Need to reassess volume (SHOW CE) ABD Assessment Pee, position, pain Sx off ~ on Look Listen Glove (if app) Feel

Skin Assessment 2 areas Moisture Edema Temperature Integrity Color

WIP

Comfort Management Comfort level Oral care Medication Bed linens Heat/cold (if assigned) Environment Reposition Distraction Backrub Ask mom (toy, feed, diaper, pacifier) Wash cloth Record Response

WIP

Exit Down bed/brakes Evaluate need Side rails up I&O Remember call light Evaluate comfort Sanitize

Other AOCs MUSC Mgmt ABN Mobility Pain w/ movement Traction ROM Assess response Supportive/therapeutic devices Heat/cold if assigned (barrier, Record response x 20 min, right temperature) O2 Mgmt Activity tolerance Oxygen administered Nail bed color/cap RF or O2 sat Skin around tubes Position Humidification Equipment (set/maintain) Record response Pain Mgmt Pain level Assess location, characteristics, duration Implement X 3 Need to reassess after 30 min Record response RESP Mgmt Position Rhythm/rate/pattern Equipment Ascultate bilaterally Tell pt breath deep/slow Hear ABN/NORM O2 sat Gloves Emesis Resp. hygiene & Reassess Pillow (splint) if app Sx <15 secs Wound Mgmt Wound drainage Observe type, appearance, location Unique cleanser/irrigant:Receptacle WIP Drainage Amount Color Remove tube (assigned) In correct cavity (assigned) Skin around (assigned) Patency Gravity WIP Specimen Container Obtain Label Transport Record Enteral Continous Id Position Verify feeding Flow NG tube Placement & residual Tubing (kinks, etc.) Volume (note) WIP Intermittent Type Exp Strength Rate Device ID Position Placement Residual I&0 Irrigation Type Temperature Amount Placement (pt & receptacle) Tube placement In correct area Rate Record WIP

WIP

WIP

WIP

Away Protect skin

Need pack/topical? Dressing-date, time, initials Record response

Patient Teaching Learning readiness Evaluate need Accurate info Reassess understanding Need to document