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mnemonics CPNE 15th
for the 15th and 16th editon of excelsior CPNE
| Question | Answer |
|---|---|
| 20 min check | wash hands introduce self/CE and ID pt check IV site w/gloves check IV rate,verify sol w/kardex amt avail doc rate sol enteral verify NGT x2 |
| I CARE | introduce/ID w/kardex choices given always listen respond to pt explain purpose |
| HIDS | hydration status:tugor,fontanelle<1 upright I&O:diet/restrictions,wt diapers 1gm=1oz encourage fluids drip rate: vol sol exp date exact ICD site check:doc in 20 mins |
| VITAL SIGNS | get baseline position properly no >30mm doc/declare take x2 |
| WASH | wash hands 30 secs always dispose sterile field hands gloved |
| SCAB | side rails up/slippers on call bell/phone in reach ask needs/assess for pain bed in low/locked position |
| REALITY | respect evaluate comfort acceptable language interaction touch yak |
| MAD ATOP | mobility status abnormalities devices (knee brace,walker,cane) ambulate turn offload position DO 1 |
| 3P'S LOOK LISTEN FEEL | potty pain position:knees flexed head flat/privacy look for distention listen for sounds/sx off feel for rigidity/suction onRECORD DATA |
| LAMP | LOC: person place time gen question to child assess fontanelle<1(flat,bulging,depressed)/noxious stimuli movement:hand grasp/push up/down AND pedal push/pull/strength/symmetry PERL |
| PTS M CC | pulses: present equal bil most distal temp: warm/cool sensation: eyes closed light touch most distal where am I touching? movement/motion: most distal wiggle toes/fingers color cap refill |
| PAIR | positon upright assess the RRAP(rate rhythm accessory muscle use pattern) instruct deep breathing/listen on skin upper/lower bil record |
| TIME 2 CC | temperature: warm/cool integrity:x2 rash,lesions, color changes,intact moisture: moist/dry edema: present/absent color cap refill |
| COMFORTERS 3 | comfort measures: do 3 observe for discomfort meds prn face wash oral care reposition treat w/heat/cold evaluate comfort at end reposition simple back rub |
| MAP HATR | mobility status abnormalities pain w/movement heat/cold apply devices traction:lines free wts free range of motion active/passive |
| SOAP | skin assessment near o2 device o2 status: o2 sat,clubbing,cap refill color activity level: tired, SOB? position upright |
| PAIN | pain scale assess comfort intervention:reposition, pain med,back rub,distraction,heat/cold,report to nurse need to reassess/record data |
| HAIR | how did pt tol deep breathing? always perform DB/C on 3rd inspiration/provide receptacle, incentive spirometry if assigned/suck in reassess after DB/C/IS |
| WOUND | wound drainage assessment(loc,appearance type) observe site unique sol(temp, delivery receptacle) need sterile field dressing |
| MARS | mar check and 5 rights(pt,med,dose,time,route)exp date,match meds to mar allergies?apical pulse labs recheck mar to pt with clean hands/match med to mar/gloves if needed sign mar ecsn/record iv condition |
| 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 and send |
| RAT FEVER | record amount and type/verify w/kardex in 20 mins fowlers examine gastric tube/abdomen verify palcement ngt aspiration and instillation 20cc air /5ml pedi and listen expiration date |
| IRRIGAT | input/verify tube placement repositon pt if necessary right sol & temp instill at correct flow good return amt of sol used tell all in doc |
| RID | readiness to learn: Is this a good time to talk about? identify learning needs: what do you know about? does pt understand? what can you tell me about what we just talked about? |
| RATIONALE | (_)is a physisological need without(_)it may interfere with his/her ability to performADL's,progress towards healing and involvement in their treatment plan.pain control oxygen-breathing water-hydration, homeostasis- balance of systems excretion-bodily |
| MMM I GLOVE I GLOVE CDS AOS | mar math med id pt glove on inspect iv glove off clamp both tubing drop primary spike air check open secondary regulate w/primary sign mar |
| TIGR OPEN PREP GLOVE PAT | tapex 4 initial id pt inspect dressing gloves on remove old in glove open supplies:4x4 tray,ns,4x4, abd,st gloves prep gauzew/ns gloves sterile pack/cover abd tape sign |
| MMM CLEAN LABEL CLEAN DIGIWA FGFS | mar math med clean tops lable 3 syringes nsx2 med clean port of bag draw up flushes x2 medx1 check mar id pt glove inspect site wipe port aspirate flush givemed over time flush sign |
| MMM RCAD RIG CAS | mar math med roll clean air:inject now then right away draw up:right away verify now 2nd verify recap plunger sterile id pt glove clean site aspirate /90 degrees sign |
| RESPIRATORY MANAGEMENT-AOC | nd-ineffective airway clearance pt will achieve comfortable pulmonary function during my pcs |
| MUSCULOSKELETAL MANAGEMENT-AOC | nd- impaired physical mobility pt will increase mobility during my pcs |
| PAIN MANAGEMENT-AOC | nd-acute pain pt will verbilize acceptable pain level during my pcs |
| COMFORT MANAGEMENT-AOC | nd-readiness for enhanced comfort pt will verbalize acceptable comfort level during my pcs |
| OXYGEN MANAGEMENT-AOC | nd- activity intolerance pt will tolerate activity without excessive fatigue during my pcs |
| WOUND MANAGEMENT-AOC | nd-impaired skin integrity |
| POTENTIAL DX | risk for falls>65 r/t unfamiliar environment pt will remain injury free during my pcs |
Created by:
tululabelle
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