| A | B |
|---|
| FLUID Management I | (1) Have You Drank Something? (2) You MUST offer the pt fluids 1x if the examiner writes “Encourage Fluids” (3) What kinds of fluids can the pt have? oral? IV? (4) Is fluid restricted for pt? |
| FLUID Management (HIDS) | (1) H - hydration status – check (a) skin turgor (tenting), mucous membranes (moist? cracked lips/tongue, sore nostrils), or anterior fontanel of child less than 1 year old (2) I input/output (3) D - drip rate – recorded in the first 20 MINUTES ! (4) S - site – Is IV site warm? Edema? |
| Child Hydration Status | (1) assess infant in upright position unless contraindicated (2) depressed if dehydrated (3) A sunken fontanelle indicates dehydration, whereas a very tense or bulging anterior fontanelle indicates raised intracranial pressure |
| Total Fluids (Fluid Management) | (1) identify fluid types being infused incl (a) amount of IV solution (b) enteral feeding (c) solids that turn to liquids (ice chips, popsicle, ice cream, jello) (2) IV solution infused must be same as indicated on cardex & ided within 20 minutes (3) do not name fluids ingested but add amount ingested to total) (4) incl amout of solution used to flush IV in total |
| Musculoskeletal Management | (1) MAP HATR (think of muscular mad hatter from Alice in Wonderland) |
| Musculoskeletal Management MAP HATR (Johnny Depp) | M - mobility status (full? partial?) A - abnormalities (with gait? is gait steady) P - pain (with movement?) H - heat or cold (apply for 20 mins unless otherwise indicated) A - apply devices (knee brace) if needed T - traction (make sure lines are unobstructed, weight hangs free) R - rom (examiner will state if you have to do (a) passive or active rom (b) upper or lower extremity(ies) (c) one or both extremity (may only be assigned R leg) |
| Physical Action | (1) when you do some type of physical action ALWAYS ask how the actions affect the patient and chart response (Feel better? More tired? Less pain? etc..,) |
| Mobility MAD ATOP | If you ambulate the patient, you must still do the last 3 actions (TURN, OFFLOAD, OR POSITION). However, when you put the patient back into bed after ambulating him/her you will be doing the last 3 automatically if you think about it |
| MAD ATOP (Mobility) | (1) M - mobility status (full? partial?) A - abnormalities (with gait?) D - devices (does the patient use a knee brace, walker, cane?) A - ambulate T - turn O - offload (PRESSURE RELIEF (EX FLOAT HEELS)) P - position |
| Ambulate | (1) if you do ambulate pt document (a) WHY (b) position pt in bed, place in a comfortable position, put body in alignment (w/a pillow behind the back &/or in between knees perhap) to complete the critical elements of turning (on to pts side/back), Offloading (pillows between knees/back/heels) Positioning (in body alignment) |
| Offload I | (1) means to reduce pressure to the skins surface. For example, elevating a pts legs on a pillow while in bed and their heels are suspended above the surface of the bed you are “floating the heels” thus “offloading” the pressure from the heels |
| Offload II | (1) when you roll the patient off their coccyx and put them on their left of right side, you have “offloaded” the pressure from the pt's coccyx and prevented a pressure ulcer formation. |
| FLUID Management II | HIDS |
| Pain | (1) PQRST (2) reassess in 1 to 2 hours for effectiveness of intervention (3) can cause nausea, diaphoresis, vomiting (4) Is expression consistant w/degree of pain? |
| Pain Assessment "P" | (1) P - (a) point to pain location or place (b) what provoked the pain (c) posture & movement - guarded & consistant with pain? |
| Pain Assessment "Q" | (1) what is the quality & descripiton of the pain? sharp, dull, stabbing? How long have you had the pain? When did it start? What were you doing when it started? Did it stop and start again or is it continuous? |
| Pain Assessment "R" | (1) does the pain radiate to other parts of the body? Where & what parts? |
| Pain Assessment "S" | (1) what is the severity of the pain on a scale of 1 to 10? Intervention needed for anything <4 |
| Pain Assessment "T" | (1) is temperature of pain location warm? tender to the touch? |
| FLUID Management "S" | (1) S - site – Is IV site warm? Edema? (2) check for infiltration, phlebitis & S/S of infectiion |
| FLUID Management "H" | (2) H - hydration status – check (a) skin turgor (b) mucous membranes (moist? cracked lips/tongue? sore nostrils? (2) is oral care needed d/t dryness (3) pinch the back of the hand and release; if tending goes away quickly, there's good hydration; if tent remains, (seconds to minutes) signs of dehydration (4) check anterior fontanel of child less than 1 year old |
| Head To Toe Nursing Assessment | http://www.youtube.com/watch?v=9Fxb8icOTOA |
| Musculoskeletal Management "T" | (1) traction – make sure the lines are unobstructed, weight hangs free – If needed |
| Musculoskeletal Management "R" | (1) ROM – examiner will state if you have to do (a) passive or active ROM (b) upper (shoulder, elbow, wrist) or lower extremity(ies) (hip, knee, ankle) (c) one or both of the extremities (i.e., you may only be assigned R leg) |
| Musculoskeletal Management "A" | (1) apply devices (like knee brace) – if needed |
| Musculoskeletal Management "H" | (1) heat or cold application (2) if needed wrap item in towel (never apply directly to the skin) & apply for 20 minutes unless otherwise indicated |
| Mobility "M" | (1) mobility status (full? partial?) |
| Mobility "A" | (1) abnormality with gait (limp? is gait steady?) |
| Mobility "D" | (1) D - devices (does the patient use a knee brace, walker, cane?) |
| Mobility "A" | (1) ambulate (2) ask if patient has pain before activity |
| Mobility "T" | (2) turn |
| Mobility "O" | (3) offload (PRESSURE RELIEF (FLOAT HEELS) |
| Mobility "P" | (1) position |
| RESPIRATORY ASSESSMENT (PAIR) | (1) P - position pt (2) A - assess the RRAP – Rhythm, Rate, Accessory muscle use, and Pattern (3) I - instruct to deep breath (4) R - record |
| RESPIRATORY ASSESSMENT "P" | (1) position patient to facilitate assessent |
| RESPIRATORY ASSESSMENT "A" | (1) assess the RRAP – Rhythm, Rate, Accessory muscle use, & Pattern |
| RESPIRATORY ASSESSMENT "I" | (3) instruct to breathe deeply & slowly |
| RESPIRATORY ASSESSMENT "R" | (1) record data (document) (a) comparison of bilateral breath sounds (b) abnormal breathing pattern (c) O2 sat (if assigned) |
| RESPIRATORY MANAGEMENT General | (1) You must place stethoscope on bare skin to assess or you fail (2) you must do the respiratory assessment menomic "PAIR" first, then you do "HAIR" mnemonic for respiratory Management |
| RESPIRATORY MANAGEMENT "HAIR" | (1) H - how did pt tolerate deep breathing? (2) A - always perform deep breathing & coughing (splint if pain) (3) I - incentive spirometry * if assigned (4) R - reassess after deep breathing/coughs/ICS |
| RESPIRATORY MANAGEMENT "H" | (1) how did pt tolerate deep breathing? |
| RESPIRATORY MANAGEMENT "A" | (1) always perform deep breathing & coughing (splint if pain) |
| RESPIRATORY MANAGEMENT "I" | (1) incentive spirometry * if assigned |
| RESPIRATORY MANAGEMENT "R" | (1) reassess after deep breathing/coughs/ICS/repositioning |
| Pain Management Critical Element "RIMR" | (1) R - reposition the pt (2) I - intervention (backrub, relaxation technique, heat & cold application as assigned) (3) M - medicate (request administration of available pain medication by assigned nurse) (4) R - record or document pain (a) location (b) descripition (c) duration) |
| FLACC Management | (1) use for (a) pain assessment (b) pain management (c) pain reassessment |
| FLACC Scale for Children | (1) use when asking a child 3 years or older to rate pain level using 0 - 5 faces scale (or age appropriate visual analog scale ) |
| FLACC Meaning | (1) (a) F - faces (b) L - legs (c) A - activity (d) C - cry (e) consolability (2) observe behaviors indicative of pain in pt unable to rate their pain (moaning, grimacing, clutching, restless) |
| Pain Reassessment | (1) did the patient’s pain level do down? Did the intervention work? |
| FLUID Management Critical Element "NG Tube" | (1) before flushing or feeding, varify placement of NG tube (not G/Peg) (a) instill 20 cc of air (5 cc for child) & auscultating (listening) for the sound of the air at the upper epigastrum site on the abdomen |
| FLUID Management Critical Element "I" | (1) Input/Output (2) CE when output is assigned (a) collect output (b) measure output during the entire PCS (c) record amount of output w/in +- 10% of the actual output |
| FLUID Management Critical Element "Input/Output" | (1) output from urinary retention catheter or other drainage apparatus is not measured during the PCS unless otherwise designated |
| FLUID Management Critical Element "Enteral/Parenteral Intake" | (a) measure the amount of fluid ingested/infused (b) record fluid intake w/in +/-10% (c) do not record solid foods, only liquids & solids that turn into liquids (ice chips, popsicle, ice cream, jello) |
| FLUID Management Critical Element "Enteral/Parenteral Output" | (a) collect ouptut (b) measure output during entire PCS (c) ????? |
| Enteral Feeding/Continuous Tube Feeding Critical Element | (1) verify NG tube location by (a) instilling 10 - 20 cc of air into the stomach while auscultating (5 ml for children under 2 yrs) (b) aspirating gastric content, measuring aspiration and reinstilling aspirated content |
| Auscultate & Palpate (Critical Element) | (1) it is imperative to perform these tasks (lungs, apical pulse, bowel sounds, etc) on bare skin |
| Palpate (Critical Element) | (1) when taking blood pressure, it is imperative to palpate the brachial artery first before applying the blood pressure cuff (2) you must take two sets of VS (BP. pulse, R) in close proximity to each other to validate your readings (p. 166) |
| Skin Assessment General | (1) provide privacy (2) remove clothing inspect skin (look at skin) What do you see? rashes, sweaty, (3) use 5 senses (smell, touch/feel (warm/cold?), see) (4) choose area of possible risk for wound dev (or already has wound i.e. cath site, IV site, ostomy, drainage shunt) |
| Skin Assessment Touch | (1) inform pt you are going to touch them (2) What do you feel? warm/cold?(3) warm means good circulation in area (4) cold means some vasoconstriction & can lead to skin break down |
| Skin Assessment "T" | (1) temperature (sign of infection) (2) feel skin temperature w/gloves on |
| Skin Assessment | (1) Time |
| Skin Assessment "I" | (1) gloves on (2) skin integrity (3) is the skin intact or broken? |
| Skin Assessment "M" | (1) moisture (wet depends) (2) diaphoretic (3) diarrhea |
| Skin Assessment "E" | (1) edema (2) assess for presence or absence |
| Skin Assessment "Color" | (1) note variation & changes (2) bruises |
| Transfers | (1) before transferring pt (a) examine & lock bed & chair wheels (b) lower bed so that pt can dangle feet to floor (c) ask pt if help in needed to a sitting position (2) pt must be wearing non skid foot wear (4) put on nonskid socks while in bed & shoes while feet dangles (5) support head & shoulders to sitting position (6) don't forget to raise bed on return and placing call light in reachable position |
| Vital Signs | (1) allow pt to become comfortable before taking VS (2) report abnormalities & drastic changes from baseline to RN, neglecting to do so could result in failure (3) place stethoscope directly on pt skin (4) manually find brachial pulse before applying BP cuff (5) measure the P, R, & BP twice w/in close time proximity before declaring your VS to validate accuracy of your readings (6) immediately write down & curcle values being submitted |
| BP Skill | http://www.youtube.com/watch?v=u6saTO8_o2g |
| BP Skill Tips | (1) check baseline (2) use arm w/no IV, fxs, etc (3) pt seated, forearm at heart level, palm up supported betw nurse's side & elbow, pt feet on floor (4) palpate pt brachial artery just below thumb (5) wrap forearm in appropriate size cuff 1 inch above elbow(6) inflate baloon keeping fingers on brachial until pulse disappears note measurement where pulse disappeared & inflate cuff 30 mmm higher & note that point (7) palpate pulse at brachial antecubital space & place scope on pulse site (8) slowly deflate cuff noting point where pulse reappears (systolic) (9) slowly release & not point where pulse disappears (diastolic) |
| Abdominal Assessment 4 Ps (Pee, Pain, Position, Pizza) | (1) P - do you have to pee (urinate)? (2) P- do you have pain? (3) P - may I help position you to prepare for examination? (flat w/knees flexed or as low as can be toletated (4) when did you last eat? (did you eat your pizza?) |
| Abdominal Assessment Sounds | (1) 3 - 30 gurgles per minute |
| Abdominal Assessment True Absence | (1) no sound for 5 minutes |
| Abdominal Assessment Performance Task | (1) wash hands (2) provide privacy (3) ask pt when was last meal (4) instruct to empty bladder (5) instruct to lie supine or semi supine w/knees bent (6) look at & inspect the abdomen (size, contour, shape, symmetry, striae, note molds, lumps, scars, pigmentation, peristalsis) (7) warm stethoscope & auscultate all 4 quad (8) percuss all 4 quads (9) palpate 4 quads (1 cm, one hand) |
| Abdominal Assessment Documentation | (1) bowel sounds (absent/present) (2) deviations from norm (distensions, rigid, tenderness,) |
| Abdominal Assessment Auscultation | (1) if the pt is on continuous gastric suctioning, turn off machine before you auscultate (how else could you hear bowel sounds?) (2) use bell (no bruits over arteries or friction rubs over perioneum |
| Musculoskeletal Management "CMS" | (1) color (2) motor function (movement in all extremities: arm, fingers, wrists, legs) (3) sensory (do they have feelings in fingers, legs? any numbness or tingling? have they lost sensation? |
| Oxygen Management "SOAP" | (1) |
| Abdominal Assessment Active Bowel Sounds | (1) active: 5 tp 30 gurgles per minute |
| Abdominal Assessment True Absence Bowel Sounds | (1) true absence: no sound for 5 minutes |
| Abdominal Assessment Normal Bowel Sounds | (1) gurgling q20 secs |
| Abdominal Assessment Palpation | (1) warm hands (2) circular motion (3) light palpation (1 cm / one hand) (4) deep palpation (4 - 5 cm: 1 1/2 - 2 in) bimanual (3) note masses or tenderness (6) bladder should not be palpable above pubic symphysis |
| RESPIRATORY MANAGEMENT Percussion of Thorax | (1) performed to find out if underlying lung tissue is filled with (a) air (b) fluid (c) solid materials (4) position & boundaries of certain organs |
| Percussion Over Fluids | (1) elicits a dull sound |
| Pneumothorax | (1) elicits hyperresonance |
| Musculoskeletal System Inspection | (1) look for (a) muscle size & symmetry (b) presence of contracture (c) tremors/spasms (d) joint swelling/deformities (e) limitations in range of motion |
| Musculoskeletal System Palpation | (1) feel for (a) muscle tone/atony (b) muscle strength bilaterally (c) joint tenderness (d) joint crepitation (e) smoothness of motion (2) do not palpate over scapula (3) do not palpate over bony areas |
| Musculoskeletal System Percussion | (1) percuss in between the ribs, the intercostal space |
| Respiratory Assessment Excursions | (1) |
| Wound Irrigation | (1) |
| RESPIRATORY ASSESSMENT Thorax Assessment "Excursion? (performed on back & chest) | (1) ask pt to breath normally & observe (a) respirations (b) buldging or interspaces w/expiration (2) resp sh/be regular, symmetrical w/no accessory muscles use (3) breath comfortably w/arms at rest (4) inspect anterior, posterior & lateral thorax (5) inspect spinal alignment & curvature & palpate the spinal processes (sh/be evenly spaced & not tender) (6) assess resp expansion w/thumbs at level of T10 (10th thorasic vertebra) w/small folds of skin bet them & fingers spread (7) w/deep, slow breaths thumbs sh/move apart symetrically 5 - 8 cm on inhalation) |
| Thorax Palpation 3 Ps | (1) palpate for warmth, tenderness, masses (2) palpate respiratory excursion for symmetry at the level of T10 (10th thorasic vertebra) (thumbs should move apart symmetrically 5 - 8 cm on inhalation) (3) palpate for vocal fremitus |
| RESPIRATORY ASSESSMENT Thorax Assessment "Tactile Fremitus" (performed on back & chest) | (1) ask pt to breath normally & observe (a) respirations (b) bulging or interspaces w/expiration (2) resp sh/be regular, symmetrical w/no accessory muscles use (3) breath comfortably w/arms at rest (4) inspect anterior, posterior & lateral thorax (5) inspect spinal alignment & curvature & palpate the spinal processes (sh/be evenly spaced & not tender) (6) assess tactile fremitus or voice sounds palpated on the chest wall surface (muffled sound normal) (7) place open palms w/fingers extended at the apexes of the lungs mmoving palms systematically down inside the scapulas down to the lower & lateral thorax feeling the vibrations as pt repeats 99 (8) in each location vibrations sh/be equal |
| youtube | http://www.youtube.com/watch?v=IidNl4xO6Mg |
| RESPIRATORY ASSESSMENT Thorax Assessment "Mediate Percussions = tapping" (performed on back & chest) | (1) ask pt to breath normally & observe (a) respirations (b) bulging or interspaces w/expiration (2) resp sh/be regular, symmetrical w/no accessory muscles use (3) breath comfortably w/arms at rest (4) inspect anterior, posterior & lateral thorax (5) inspect spinal alignment & curvature & palpate the spinal processes (sh/be evenly spaced & not tender) (6) starting at the apexes (move from bilaterally R to L (to compare sides), place the lenght of the middle finger laterally in the first intercostal space at the top of the shoulder just above the scapula (lung apexes) & tap just behind the fingernail (7) resonance sh/be equal over the lungs (8) dullness over the diaphragm (9) hyperresonnance means an area of >air in the lungs or pleural space, as w/pneumothorax or acute asthma (10) abnormal dullness indicated <air in the lungs as w/atelectasis or a build up of pleural fluid |
| RESPIRATORY ASSESSMENT Diaphragmatic "Excursion" (performed on back & chest) | (1) ask pt to breath normally & observe (a) respirations (b) buldging or interspaces w/expiration (2) resp sh/be regular, symmetrical w/no accessory muscles use (3) breath comfortably w/arms at rest (4) inspect anterior, posterior & lateral thorax (5) inspect spinal alignment & curvature & palpate the spinal processes (sh/be evenly spaced & not tender) (6) ask pt to exhale & hold breath (7) on the L side percuss the intercostal spaces from the bottom of the scapula down to where sound changes to dullness & mark spot w/a pen (8) ask pt to inhale deeply & hold breath as you percuss further down the L side to a new area of dullness (9) mark this spot (10) repeat entire process on the R side (11) measure the distance between the set of marks on the L side then R side (12) this distance representing diaphragmatic excursion normally is 3 to 5 cm & is equal on both sides |
| RESPIRATORY ASSESSMENT Auscultation of Breath Sounds | (1) ask pt to breath normally & observe (a) respirations (b) bulging or interspaces w/expiration (2) resp sh/be regular, symmetrical w/no accessory muscles use (3) breath comfortably w/arms at rest (4) inspect anterior, posterior & lateral thorax (5) inspect spinal alignment & curvature & palpate the spinal processes (sh/be evenly spaced & not tender) (6) ask pt to breath deeply thru mouth (7) starting at lung apexes, auscultate the lungs bilaterally (listen for one complete respiration at each point) (8) normal breath sounds vary from location to location (9) (a) sh/hear bronchovesicular sounds bet the scapulae (moderate in pitch & amplitude, equal in duration w/equal inspiratory & esxpiratory phases (11) sh/hear vesicular sounds at the apexes, at the bases & laterally (low pitched & soft w/a longer inspiratory than expiratory phase) (12) abnormal sounds (crackles & wheezes, coughing (ask pt to cough then reassess for clearance) & abnormal efforts (13) |
| Crackles | (1) can be heard on inspiration & sometimes on expiration (2) result from collapsed or fluid filled alveoli popping open (3) they have a fine crackling or sometimes bubbling sound |
| Pain "Five Fast Assessment: OLD CART" | (1) O -onset (2) l - location (3) D - duration (4) C - characteristics (5) A - aggravators (6) R - relievers (7) T - treatment (8) S- scale (0 to 10) |
| Wheezes (performed on back & chest) | (1) can be heard on inspiration or expiration are high or low pitched (2) indicate airway obstruction (3) if abnormality is suspected have pt say 99 while auscultating around the lung base (normally 99 sounds muffled & indistinct) |
| O2 documentation | (1) pt response to activity level (2) oxygenation status (Px result) (3) condition of skin surfaces in contact w/O2 delivery system (4) oxygenation management measures implemented (5) patient response to measures implemented |
| O2 Management "SOAP" | (1) S - skin assessment (a) nasal & oral mucousa membranes (b) skin around cannula, face mask, ears) red? intact? (2) O - oxygen status (a) O2 sats or cap refill (b) provide oral care q8hrs (3) A - activity level (assess pt response to activity (4) P - (a) position pt to (i)facilitate breathing (ii) allow maximum chest expansion |
| O2 Management Precautions | (1) post sign "No Smoking Oxygen In Use" (2) remove lighter, electric razors (3) know the location of fire extinguisers |
| O2 Therapy 5Ps | (1) provide oral care q8hrs (2) position pt to facilicate breathing (3) position tubing to avoid traction (4) pad tubing in area that put pressure on skin (5) use non patroleum cream on pt skin, nostrils, face & lips |
| O2 Therapy "Humified O2" | (1) if pt's humidified O2 runs out, replace it unless contraindicated |
| Pulse & Respiration | (1) count for 1 full minute (2) count the first two or three heart beats out loud to make sure you are in zinc w/the examiner, then count softly (3) verbalize stop upon reaching a full minute (4) if the radial pusle is irregular or difficult to obtain, it is okay to change to an apical (not allowed to change from an apical order to a radial, however) |
| Weight Measure | (1) balance the scale first (2) undress the pt as necessary (3) maintain cleanliness of the scale (clean weights &/or scale after use) (use a barrier on the scale like gloves, or paper towel if the pt is an infant or child to be weighed lying down) (4) weighing w/in 1% of the correct weight |
| Neurological Assessment "LAMP" | (1) L - loc oriented to person, place, time or ability to recognize familiar people (2) A - assess anterior fontanelle in child <1 yr (flat? buldging? depressed? (3) M - movement (a) hand grasp/push down & up & pedal push/pull (b) squeeze both hands simultaneously (c) dorsifles or plantar flex both feet simultaneously (4) P - perla (a) pupil, equal & reactive to light |
| Neurological Assessment "Noxious Stimuli" | (1) response to pain from a pt who is non responsive to verbal stimuli (2) to effect, nurse sh/push her thumbnail into the unresponsive pt's nailbed & document the pt's response |
| youtube thorax assassment | http://www.youtube.com/watch?v=IidNl4xO6Mg |
| Respiratory Excursions | (1) to assess resp expansion/excusion place each both thumbs on R & Left sides simultaneously at level of T10 (10th thorasic vertebra) w/small folds of skin bet them (2) fingers on both hands sh/spread away from the thumbs to the waist (3) ask pt to take deep, slow breaths (4) thumbs sh/move apart symetrically 5 - 8 cm on inhalation) |
| Positioning/Repositioning | (1) to allow for maximum chest expansion (2) encourage frequent position changes (ambulate/exercise) (3) for bed-confined pt (4) facilitate turning from side to side |
| Respiratory Fremitus | (1) assess tactile fremitus or voice sounds palpated on the chest wall surface (muffled sound is normal) (2) place open palms w/fingers extended upward at the apexes of the lungs moving palms systematically down (forming backward C on L & forward C on R) inside the scapulas down to the lower & lateral thorax feeling the vibrations as pt repeats 99 (3) in each location vibrations sh/be equal |
| you tube lab wound Station | http://www.youtube.com/watch?v=m0SMl3ESK-o&NR=1 |
| you tube IV Pusg Station | http://www.youtube.com/watch?v=W5h9bEyuZ4Q |
| you tube IV Drip Station | http://www.youtube.com/watch?v=Arh8yllnUxA |
