Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
15th ed CPNE
help with studies for the dreaded CPNE
| Question | Answer |
|---|---|
| Respiratory Management | Ineffective airway clearance |
| Musculoskeletal management | Impaired physical mobility |
| Comfort management | Readiness for enhanced comfort |
| Oxygen management | Activity intolerance |
| Pain management | Acute pain |
| Planning phase | 2 nursing dx with outcome and interventions. calculate gravity iv. write down meds to be given se uses teaching points labs h&h pt inr ptt dig na bun last pain med vs adl's |
| 20 min check | wash hands in sight of CE introduce self/CE check iv site-gloves check iv rate/verify solution w/ kardex & amt available verify ngt placement x2 document rate/solution of iv/enteral solution |
| Caring | I CARE |
| Fluid management | Have I drank something-Hids |
| VS | T P R BP WT O2SAT PAIN |
| Asepsis | WASH |
| Physical jeopardy-safety | SCAB |
| Emotional Jeopardy | REALITY |
| Abdominal assessment | 3P's then look listen feel |
| Neurological assessment | LAMP |
| Peripheral Vascular assessment | PTS M CC- post traumatic stress move cc |
| Respiratory assessment | PAIR |
| Skin Assessment | TIME CC |
| Mobility | MAD ATOP |
| Comfort management | COMFORTERS 3 |
| Musculoskeletal management | MAP HATR |
| Oxygen management | SOAP |
| Pain management | PAIN |
| Respiratory management | HAIR must do assessment first (PAIR) |
| Wound management | WOUND |
| Medication | WATCH MARS |
| Drain/Specimen | I SPECIAL |
| Enteral Feeding | RAT FEVER |
| Irrigation | IRRIGAT |
| Pt Teaching | RID |
| Rationale 1 | _ is a physiological need, without _it may interfere with his/her abilityto perform ADL's, progress towards healing and involvement in their treatment plan. |
| Rationale 2 | _ is a basic human need. If _ is adequately addressed the patient is more likely to participate in the treatment plan, healing will progress as expected and the patient should return to their pre-hospitalization functionality. |
| physiological needs | breathing-oxygen water-hydration food-nutrition sleep-rest excretion-bodily elimination homeostasis- balance of systems(temp/fluids) |
| Planning phase | 2 nursing dx with outcome and interventions. calculate gravity iv. write down meds to be given se uses teaching points labs h&h pt inr ptt dig na bun last pain med vs adl's |
| 20 min check | wash hands in sight of CE introduce self/CE check iv site-gloves check iv rate/verify solution w/ kardex & amt available verify ngt placement x2 document rate/solution of iv/enteral solution |
| Caring | I CARE |
| Fluid management | Have I drank something-Hids |
| VS | T P R BP WT O2SAT PAIN |
| Asepsis | WASH |
| Physical jeopardy-safety | SCAB |
| Emotional Jeopardy | REALITY |
| Abdominal assessment | 3P's then look listen feel |
| Neurological assessment | LAMP |
| Peripheral Vascular assessment | PTS M CC- post traumatic stress move cc |
| Respiratory assessment | PAIR |
| Skin Assessment | TIME CC |
| Mobility | MAD ATOP |
| Comfort management | COMFORTERS 3 |
| Musculoskeletal management | MAP HATR |
| Oxygen management | SOAP |
| Pain management | PAIN |
| Respiratory management | HAIR must do assessment first (PAIR) |
| Wound management | WOUND |
| Medication | WATCH MARS |
| Drain/Specimen | I SPECIAL |
| Enteral Feeding | RAT FEVER |
| Irrigation | IRRIGAT |
| Pt Teaching | RID |
| Rationale 1 | _ is a physiological need, without _it may interfere with his/her abilityto perform ADL's, progress towards healing and involvement in their treatment plan. |
| Rationale 2 | _ is a basic human need. If _ is adequately addressed the patient is more likely to participate in the treatment plan, healing will progress as expected and the patient should return to their pre-hospitalization functionality. |
| physiological needs | breathing-oxygen water-hydration food-nutrition sleep-rest excretion-bodily elimination homeostasis- balance of systems(temp/fluids) |
| IVMB STATION | MMM I GLOVE I GLOVE CDS AOS |
| WOUND PROTECTION STATION | TIGR OPEN PREP GLOVE PAT |
| IV PUSH STATION | MMM CLEAN LABEL CLEAN DIGIWA FGFS |
| IM/SUBCUT STATION | MMM RCAD RIG CAS |
| AOC | Respiratory management musculoskeletal management comfort mangaement oxygen management pain management |
| ND | ineffect airway clear impair phys mob readi for enhan comfort activity intol acute pain |
| I CARE | Introduce/ID w/kardex Choices given Always listen Respond to pt Explain purpose |
| HIDS | Hydration status-turgor fontanel<1 upright I and O's diet/restrictions wt diapers 1gm/1oz encourage fluids Drip rate vol of sol exp date exact on ICD Site check doc in 20 mins |
| Vital Signs | get baseline position properly compare to baseline 30mm document/declare |
| WASH | wash hands always dispose sterile field hands gloved |
| SCAB | side rails up/slippers oncall bell/phone in reach ask need/assess for pain bed in low/locked position |
| REALITY | respect evaluate comfort acceptable language interaction touch yak |
| MAD ATOP1 | mobility status abnormalities devices(does a pt use a brace, walker)ambulate turn offload position must do 1 of the last 4 |
| 3 P'S LOOK LISTEN FEEL | potty does pt have to urinate pain is the pt in pain position flat with knees flexed or as low as the pt can tol/privacy look for distention listen for bowel sounds/suction off feel for tenderness rigidity/sx on record data |
| LAMP | LOC- person place and time gen question to child/noxious stimuli asssess fontanelle<1(flat bulging depressed) movement hand grasp/push down and pedal push/pull/strength/symmetry strength PERL |
| PTS M CC | pulses present equal and bil most distal temp warm/cool sensation tactile close eyes most distal movement/motion motor function most distal wiggle toes/fingers color/cap refill <3sec |
| PAIR | position pt upright assess the RRAP rhythm rate accessory muscle use and pattern instruct to deep breathe/listen over skin upper lower bil record |
| TIME CC | temperatureintegrity x2 occiput trochanters heels sacrum/coccygeal skin folds perianal for rash lesion color changes moisture edema present or absent color cap refill |
| COMFORTERS 3 | comfort measures do 3 observe for pain meds prn face wash oral care relaxtion treat with heat or cold evaluate comfort at end reposition simple back rub |
| MAP HATR | mobility status abnormalities pain with movement heat or cold apply devices traction lines free wts free range of motion passive or active |
| SOAP | skin assessment check skin around the cannula face mask- intact red?oxygen status 02 sats cap refill color clubbing activity level assess pt response tired sob? position fowlers |
| PAIN | pain scale assess comfort interventions reposition backrub distraction heat/cold pain meds report to nurse need to reassess record data |
| HAIR | how did pt tol deep breathing? always perform deep breathing and cough 3rd inspiration/provide receptacle incentive spirometry suck in reassess after deep breathing/cough/ics |
| WOUND | wound drainage assessed loc, appearance type observe site unique irrigation & clean sol temp delivery need sterile field dressing |
| WATCH MARS | wash hands acquire meds match med to mar exp date 5 rights(pt med dose route time)take meds in room clean hands w/ meds in site have gloves mar check and 5 rights to pt allergies apical pulse check recheck MAR to meds and give Sign MAR |
| I SPECIAL | ID pt specimen collected place tube properly examine color odor consistency appearance clean surrounding skin I& O recorded assess condition of site label& send |
| RAT FEVER | record amount of formula and type of formula /verify w/kardex in 20 min fowlers examine gastric tube/abdomen verify placement ngt placement by aspiration and instillation of 20 cc air 5cc for pedi and listen record in 20 mins |
| IRRIGAT | Input/verify tube placement reposition pt if necessary right solution & temp instill at correct flow amt of sol used tell all in doc & pt response |
| RID | readinesss to learn mr smith is this a good time to talk about_?identify learning needs- mr smith what do you know about_?does pt understand? mr smith what can you tell me about what we just talked about? |
| MAR MATH MED I GLOVE IGLOVE CDS AOS | ID PT GLOVE ON INSPECT IV SITE GLOVES OFF CLAMP BOTH TUBING DROP PRIMARY BAG SPIKE BAG AIR CHECK AND REMOVE OPEN SECONDARY COMPLETELY/REGULATE W/ PRIMARY SIGN MARS |
| TIGR OPEN PREP GLOVE PAT | TAPE TEAR 4 STRIPS AND INITIAL ONEID PT/ INSPECT DRESSING GLOVES ON REMOVE OLD DRESSING INSIDE OF GLOVE AND DISPOSE OPEN SUPPLIES ABD 4X4 4X4 TRAY SALINE ST GLOVES PREP 4X4 TRAY W/NS GLOVES ON STERILEPACK WOUNDS/COVERW/DRY 4X4 ABD TAPE |
| MMM CLEAN LABEL CLEAN DIGIWA FGFS | CLEAN TOPS OF MEDS LABEL 3 SYRINGES NSX2 MEDSX1 CLEAN NS PORT OF BAG TO DRAW FLUSHES DAW UP FLUSHES/MED CHECK MARID PT GLOVE INSPECT IV SITE VERBALIZE WIPE IV SITEASPIRATE FLUSH W/NS 10-15 SECS GIVE MED OVER PRESCRIBED TIME FLUSH W/NS SIGN MAR |
| MMM RCAD RIG CAS | ROLL CLEAN AIR INJECT NOW THEN RIGHT AWAY DRAW UP RIGHT AWAY VERIFY NOW 2ND VERIFY RECAP PLUNGER STERILE ID PT GLOVE UP CLEAN SITE ABD/VG/VL ASPIRATE 90 DEGREES SIGN MARS |
Created by:
tululabelle
Popular Nursing sets