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

20 Minute Checks W=wash, I=ID, P=privacy

Fluid Management Hydration Enteral (offer if encourage fluid)


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) NEURO Assessment WIP Consciousness x 3 (or observe/stimulate) Anterior Fontanel (if app) PERL Equality Stimuli

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

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 WIP

MEDs WIP MARMedExpiration 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 WIP Position Rhythm/rate/pattern Equipment Ascultate bilaterally Tell pt breath deep/slow Hear ABN/NORM O2 Sat

Skin Assessment WIP 2 areas Moisture Edema Temperature Integrity Color

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

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

Record Response

Other AOCs MUSC Mgmt ABN Mobility Pain w/ movement Traction ROM Assess response Supportive/therapeutic devices Heat/cold if assigned (barrier, Record response temperature) x 20 min, right O2 Mgmt WIP 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


Drainage Specimen Amount Container Color Obtain


Enteral Continous Id Type Position Exp Verify feeding Label Record Flow Rate NG tube Placement & residual Tubing (kinks, etc.) Volume (note) Residual I&0



Irrigation WIP Type Temperature Amount Placement (pt & receptacle) Tube placement In correct area Rate ID Record

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


Remove tube (assigned) Skin around (assigned) Patency Gravity

In correct cavity (assigned) Transport

Device Position Placement

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