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Grid

Grid

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Published by Carmen Martinez
I made this grid when reading the study guide...I still have some critical element missing
I made this grid when reading the study guide...I still have some critical element missing

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Published by: Carmen Martinez on Mar 24, 2012
Copyright:Attribution Non-commercial

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10/21/2014

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GRID:Enter 20 min check Rqst supplies needed ExitPresentID PTPlace PCS formAsk comfortWash handsElevate bedTurgorIV (rate, type)IV site-gloves Check SocksGloves of your sizeDouble stethoProtective barrierfor scaleCollection device-output at bathroomFlashlight forpapillary responseAmplificationdevice-non palpableperipheral pulsesWound-contactprecaution policyProvide call lightLower bedWash hands in front of CECritical ElementsMobility Fluid managementGait?, abnormality?,device?Moves 4 extremitiesfreely?10 min restReady to move?Stabilize equipment(brakes engages)Position equipmentfoot weardyspnea? Pain?RecordIntake:Measure PO/infusedRecordOutput:Collect (no catheter)If bathroom-ask forcollection deviceMeasureRecordWeight diapers:DO NOT DISCARDDIAPERS-parentsFormed stoolsweighed?Protective barrierEnteral:Administer/restrictfluids
“encourage”—
offerfluidsParenteral:Start New IV:
(Same as Labs)
Select medCalculateID ptGlove upAssess IVClear airRegulate flowRecord flow
IVAD Maintenance:
Glove up @ all times
Assess siteAspirate for blood (unlesscontraindicated)Flush with Rx solutionGlove off Wash handsRecord the flush on PCSform
Discontinue IV:
Glove UpAssess siteRemove cannulaApply pressureApply protective covering
 
V/SGeneralCheck last 24 hrs v/s onchartAsk CE for doubleStethoscope for BP andapical pulseWarm Stethoscope andapply on direct skin Measure x 1 minReport changes onbaseline to nurseRecordCircle chosen v/s from1
st
and 2
nd
set
“Declare your v/s”
 Pain:
Adults:
0-10 scale
Child:
0-5 FACES scale
2 mth-3 yrs:
FLACCscale
Non verbal:
observebehavior (same as inFLACC scale)CE will assesssimultaneouslyPulseError range:adults: + 5 bpm< 2yr: + 10 bpmApical(double stetho) 
 
pts < 3yrs
 
irregular HRRadial-adultsPalpate both wrist andchoose the best oneFeel pulse beforecountingCE will countsimultaneously on theother wrist after makingsure bilateral pulses areequal.Temperature:Error range:+ 0.2Axillary/Temporaltympanicoral/rectal
Glove up! BP(double stetho) Error range:+ 6 mmManual BP-adultsRespirationError range:adults: + 2 bpm< 2yr: + 6 bpmWeight:Error range:+ 1%Balance scale priorweighing!Do not weight patientright after foodingestion.Ask nurse:
 
Weight withclothes/diapers?
 
Subtract weight of clothes/diapers?
 
Routine time toweight ptsProtective barrierMeasureRecordAbdominal Assess Neuro Assess
(start at the top and work down)
 Peripheral VascularAssessSkin--- 
CITEM
 (
Assess 2 surfaces
)Full bladder?PrivacyPosition ptComfort?Warm hands and stethoInspect (look)
Expose entire abdomen
Auscultate BP(doublestetho)
If continuous gastricsuctioning-turn off machine prior listening!!!
Palpate lightly (feel)
Pain? Discomfort?Fullness?
Review chartorientation:
1.
 
Time/place/personor2.
 
Recognize familiarpeople or commonobjectsor
Pupillary responsein adarkened room: -
 
Equal pupil size-
 
Reaction to lightEqual motor responsePalpate & compare:
-palpatepresence/absence of 
most
 distal pulsessimultaneously! -compare the most distalpulses bilaterally.
Perfusion
Check capillary refill(2-3digits!!)/ observe color
Assess temperature
Touch distal portions of assigned extremities
Tactile stimuli
(Assess 2 to 3 digits onAsk if pt isbedbound/wheelchairboundAssess-
 
Color (pallor,cyanosis)-
 
Integrity (lesion, rash,pressure ulces)-
 
Temperature (cool,warm)
-
 
Edema(present/absent)
 -
 
Moisture (colostomy,diarrhea,incontinence)
 Record for each area
 
Identify tender areas andpalpate them last!
Check gridRecord
 -
 
Squeeze middle andindex finger bilateralsimultanously-
 
Dorsiflex or plantaflexfeet simultaneouslyagainst resistance 
Add assess to non-verbal pt or 1-3 yrs pt :Orientation:
3.
 
For non-verbal or 1-3yrs:Present visual, auditory, &tactile stimuliIf no response to verbalstimuli-do a noxiousstimuli (pressure to thenailbed)
Musculoskeletalresponse:Check for symmetry andmovement of 4extremitiesAdd assess on <1 yr pt :Orientation:
4.
 
observe how pt reactsto presence of familiar person/object
Palpate anteriorfontanel with child inupright position, head90 degrees.
each limb)Ask pt toclose eyes&determine if feels yourtouch on theirfingers/toes
Motor function
-
 
Ask pt to moveextremity
-
 
Non verbal/ <3yr:observe mov of extremities
 RecordWound mgment
(if contact precaution is needed (MRSA or VRE), ask for contact isolation policy)
 1.
 
Remove soileddressing2.
 
Assess:
-
 
Location & woundtype-
 
Drainage-
 
Wound bed-
 
Drains(present/absent)-
 
s/s of infection-
 
inflammation-
 
progress of healing
If cleanseDecide is Px is sterile orclean1.
 
Prepare supplies2.
 
Clean from the leastcontaminated tothe most
(Use a 4x4 for every cleansing)
If drain-use circularmotion near the drainout from the insertionIf packing
(same as labs):
Wet gauze cannot come incontact with intact skin!!
1.
 
Prepare sterilesupplies2.
 
Apply sterile gloves3.
 
Apply sterilepacking gauze (wetto dry)4.
 
Abd pad(blue tosky) If irrigation
*use syringe withappropriate gauge for  pressure needed 
 1.
 
Select solution2.
 
temperature of solution(TPEA) 3.
 
Use appropriateirrigation system4.
 
Positions areceptacle forreturn flow

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