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CPNE

CPNE

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Published by Raf Luis
Nclex Review Guide!
Nclex Review Guide!

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Published by: Raf Luis on Nov 21, 2010
Copyright:Attribution Non-commercial

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04/29/2014

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First thing-wash hands-id pt, self & ce-ask comfort/pain-glove prn-do 20 min checksFluid management-turgor -drip rate-site check-I&O-record20 minute checks-i.v. site-i.v. tubing-i.v. flow rate & fluid infusing-g tube site check-g tube tubing-g tube flow rate & fluid infusing-O2 flow rate-cannula & tubingMobility-assess level of mobility-assistive devices-position-support injured limbs-transfer/traction if ordered-balance-recordVital signs-drank nothing 15 min before temp-glove for oral temp-clean scale after use-surgery site/iv arm = no b/p-balance scale before use-palpate brachial artery for b/p-measure O2 sat if ordered
 
-do not re-inflate b/p for 1 min-barrier for scaleVital signs: List of 7-temp-HR/pulse-b/p-resp-O2 sat-pain scale-weightExit-bed low-side rails up x2-phone in reach-ask comfort level/pain-wash hands-recordSkin assessment-assess in 2 locations-color -integrity-temp-edema-moisture Abdominal assessment-pee-position-pain-look-listen-feel-measure girth (if ordered)-recordNeuro assessment-LOC (A&O, person, place, time)-PERRL-Fontanel if <1 year 
 
-motor response- grasps/pushes-noxious stimuli-recordPeripheral vascular assessment-pulses-movement-sensation-temp-cap refill-edemaRespiratory assessment-O2 sat if ordered-fowlers position/ HOB up-sounds bilaterally-pattern/rate-accessory muscle use?-labored?-Lobes (document upper and lower)Respiratory management-position-receptacle-assess: rate, rhythm, sound-perform measure (IS,DB,Cough)-splint if necessary-reassess-recordMusculoskeletal management-joints-assess-movement-strength-flexibility-traction if ordered-heat-cold-re assess

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