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Published by: John MelanconPhotography on Mar 09, 2013
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03/09/2013

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Enter WashIntroIDNeed? (Caring)
Comfort/sleep well?
20 Minute Checks
W=wash, I=ID, P=privacy 
 Fluid Management
WIP
 
HydrationEnteral
(offer if encourage fluid)
Parenteral w/ Kardex
(fluid,rate,tubes)
 Assess site w/ glovesRegulate rateRecord fluids infusing
(note volume)
I & ONeed to reassess volume(SHOW CE)V/ST
(O, ax, temporal, tympanic)
P
(radial, apical)
RB/P
(manual, automatic)
Wt
(balance scale, barrier, undress,Prior to eating/feeding)
O2 satPain level(SHOW CE)Mobility
WIP
Moves
(equally, freely, no difficulty)
 ABN balanceDevices
(walker, abductor pillow)
 Ambulate/AlignTransfer/turn/liftPosition w/ supportObserve gait/balancePt responseSafety
(Stabilize equipment, footwear)
 MEDs
WIP
MAR
Med
Expiration Appropriate DoseRecheck MAR w/ IDDo 5 rightsObserve allergiesSpecial Assessments
(b/p, pulse, bruising,bleeding pain level)
 Ask how takes?Gather suppliesEvaluate/administer Sign MAR ABD Assessment
WIP
 
Pee, position, painSx off 
~
onLookListenGlove (if app)FeelNEURO Assessment
WIP
Consciousness x 3 (or observe/stimulate) Anterior Fontanel (if app)PERLEqualityStimuliPVA
WIP
 Palpate pulsesCompare bilaterallyPerfusion (color or cap RF)TemperatureTactile stimulationMotor movementRESP Assessment
WIP
 PositionRhythm/rate/patternEquipment Ascultate bilaterallyTell pt breath deep/slowHear ABN/NORMO2 SatSkin Assessment
WIP
 2 areasMoistureEdemaTemperatureIntegrityColor Comfort Management
WIP
 Comfort levelOral careMedicationBed linensHeat/cold (if assigned)EnvironmentRepositionDistractionBackrub Ask mom (toy, feed, diaper, pacifier)Wash clothRecord ResponseExitDown bed/brakesEvaluate needSide rails upI & ORemember call lightEvaluate comfortSanitize
 
 
Other AOCsMUSC Mgmt
WIP
 ABNMobilityPain w/ movementTractionROM Assess responseSupportive/therapeutic devicesHeat/cold if assigned
(barrier,
Record response
 x 20 min,right temperature)
 O2 Mgmt
WIP
 Activity toleranceOxygen administeredNail bed color/cap RF
or 
O2 satSkin around tubesPositionHumidificationEquipment (set/maintain)Record responsePain MgmtPain level Assess location, characteristics, durationImplement X 3Need to reassess after 30 minRecord responseRESP Mgmt
WIP
PositionRhythm/rate/patternEquipment Ascultate bilaterallyTell pt breath deep/slowHear ABN/NORMO2 satGlovesEmesisResp. hygiene & ReassessPillow (splint) if appSx <15 secsWound Mgmt
WIP
Wound drainageObserve type, appearance, locationUnique cleanser/irrigant:
Receptacle  Away Protect skin 
Need pack/topical?Dressing-date, time, initialsRecord responseDrainage
WIP
Specimen Amount Container Color ObtainRemove tube (assigned) LabelIn correct cavity (assigned) TransportSkin around (assigned) RecordPatencyGravityEnteral Continous
WIP
IntermittentId TypePosition ExpVerify feeding StrengthFlow RateNG tube Placement & Deviceresidual IDTubing (kinks, etc.) PositionVolume (note) PlacementResidual
 
I & 0Irrigation
WIP
TypeTemperature AmountPlacement
(pt & receptacle)
Tube placementIn correct areaRateRecord

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