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

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

Fluid Management WIP Hydration Enteral (offer if encourage fluid) 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)

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)

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)

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

ABD Assessment Pee, position, pain Sx off ~ on Look Listen Glove (if app) Feel


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

PVA WIP Palpate pulses Compare bilaterally Perfusion (color or cap RF) Temperature Tactile stimulation Motor movement

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 Record Response

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, temperature)



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


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

Drainage WIP Specimen Amount Container Color Obtain Remove tube (assigned) Label In correct cavity (assigned) Transport Skin around (assigned) Record Patency Gravity

Enteral Continous WIP Intermittent Id Type Position Exp Verify feeding Strength Flow Rate NG tube Placement & Device residual ID Tubing (kinks, etc.) Position Volume (note) Placement Residual I&0

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

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

Sign up to vote on this title
UsefulNot useful