-wash hands -id pt, self & ce First thing -ask comfort/pain -glove prn -do 20 min checks -turgor -drip rate

Fluid management -site check -I&O -record -i.v. site -i.v. tubing -i.v. flow rate & fluid infusing -g tube site check 20 minute checks -g tube tubing -g tube flow rate & fluid infusing -O2 flow rate -cannula & tubing -assess level of mobility -assistive devices -position Mobility -support injured limbs -transfer/traction if ordered -balance -record -drank nothing 15 min before temp -glove for oral temp -clean scale after use Vital signs -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 scale -temp -HR/pulse -b/p Vital signs: List of 7 -resp -O2 sat -pain scale -weight -bed low -side rails up x2 -phone in reach Exit -ask comfort level/pain -wash hands -record -assess in 2 locations -color -integrity Skin assessment -temp -edema -moisture -pee -position -pain -look Abdominal assessment -listen -feel -measure girth (if ordered) -record -LOC (A&O, person, place, time) Neuro assessment -PERRL -Fontanel if <1 year

-motor response- grasps/pushes -noxious stimuli -record -pulses -movement -sensation Peripheral vascular assessment -temp -cap refill -edema -O2 sat if ordered -fowlers position/ HOB up -sounds bilaterally Respiratory assessment -pattern/rate -accessory muscle use? -labored? -Lobes (document upper and lower) -position -receptacle -assess: rate, rhythm, sound Respiratory management -perform measure (IS,DB,Cough) -splint if necessary -reassess -record -joints -assess -movement -strength Musculoskeletal management -flexibility -traction if ordered -heat -cold -re assess

-pain -chart -glove -assess: location, type, appearance of drainage -irrigation if ordered Wound management -cleanse wound w/designated solution -topical med if ordered -dressing change if ordered -record -assess response to activity -observe nail beds -position HOB up -flow rate O2 management -humidification -articles of hazard -skin under tubing -sats if ordered -record -rate pain -ask about comfort -observe signs & symptoms Pain/comfort management -medicate or inform primary nurse -do 3 measures -reassess -response/record -select med -measure dose Medication -pt i.d. -administer within 30 min -MAR documentation within 30 min -check gtts Intermittent tube feeding -check placement

-check residual -determine amount of feeding -administer within 30 min -adjust flow rate -record -readiness to learn Patient teaching -what is being taught -patient understanding -feeding type -position -check placement Enteral feeding -residual -burp if <6 months -at room temperature -record -assess: color, amount, consistency -clean surrounding tissue if ordered -insert tube if ordered Drainage collection -maintain patency/position -remove tube if ordered -record -select volume, ready patient, instill and record -select solution -temp -verify tube placement Irrigation -receptacle -position -instill slowly -record -obtain speciment in proper container Speciment collection -label appropriately -observe: color, consistency & odor

-how was the speciment collected? -where is it going? -record

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