CPNE Documentation-Buzz words
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| show | stand or reposition self, Supported with pillows, proper alignment maintained, ambulation, complaints of, gait/balance, pt response "...."
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| SKIN ASSESSMENT | show 🗑
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| show | distention, Bowel sounds present all four quadrants, rigidity, tenderness, tolerated procedure, knees flexed, pt supine, supine with knees flat
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| RESPIRATORY ASSESSMENT | show 🗑
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| show | Bilateral, distal, pulses, equal, strong, pedal, Skin warm, pink, non-edematous, Moves all, dull/sharp sensations,
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| NEUROLOGICAL ASSESSMENT | show 🗑
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| RESPIRATORY MANAGEMENT | show 🗑
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| show | resting comfortably, Pain on 0-10 scale, linen change, Repositioned, "quote pt statements", mouth care, Washed hands and face
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| show | Hydration status (turgor, MM, fontanel)
IV site Appearance (temp, edema)GLOVES ON
IV solution infusing &verify Rate/GTTS) SAME W/ CONTIN.FEEDINGS (sol/rate)
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| show | pain, medicated, AROM exercises, PROM, Assisted with flexion/extention, abduction/adduction, tolerated,
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| show | Pt response to activity (SOB, dyspnea on exertion after repositioning, ambulating, or participating in activities)
O2 device & rate (2l via NC)
Oxygentation Status-(measure O2 Sats or CRT/nailbed color, or clubbing)
Skin condition and pt response
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| show | Pain level (scale, flacc, faces) OLD CART
Adm pain meds? or reported info to the RN
What pain relief measure you implemented(backrub)
pt pain level on reassessment (pt response)
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| show | medicated, intact blister, drainage, serous fluid, Skin red, warm, intact, Applied..ordered, Patient tol,
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| show | 1. pts readiness to learn (doc quest/pt resp)
2.learning needs (Ask ? to eval.prior knowledge and what they want to learn)
3. Information taught to the pt. ID barriers/KISS
4.Determine pt understanding of teaching (pt explains what he learned)""
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| PRIORITY CP STATEMENT | show 🗑
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Created by:
chel4u84