CPNE Documentation-Buzz words

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Question

Answer

MOBILITY

stand or reposition self, Supported with pillows, proper alignment maintained, ambulation, complaints of, gait/balance, pt response "...."

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SKIN ASSESSMENT

Color changes, Integrity (ex. lesions, rash, tears, etc.) Skin Temp., Edema, Moisture (perspiration, incontinence, diarrhea, non-intact ostomy/drainage system)

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ABDOMINAL ASSESSMENT

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

fowlers position, Comparison of Breath sounds bilateral upper and lower lobes, Abnormal breathing patterns (Labored/Non-labored, even). No obvious accessory muscle use. O2 Sat

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PERIPHERAL VASCULAR ASSESSMENT

Bilateral, distal, pulses, equal, strong, pedal, Skin warm, pink, non-edematous, Moves all, dull/sharp sensations,

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NEUROLOGICAL ASSESSMENT

Eyes open, PERRL, grasp hands or move feet, Noxious stimuli, Patient withdraws or grimaces, Awake, alert, oriented to person, place, time, grasp and dorsi-plantar flexion strong. Wiggles all fingers and toes, bilaterally.

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RESPIRATORY MANAGEMENT

abnormal, upper and lower lobes, bilaterally, accessory muscle use, rate and depth, Suctioned, unchanged, improved, Posterior, coughed, fowlers, labored, even, non-labored, Instructed to deep breathe and cough x3, non-productive, incentive sp

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COMFORT MANAGEMENT

resting comfortably, Pain on 0-10 scale, linen change, Repositioned, "quote pt statements", mouth care, Washed hands and face

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FLUID MANAGEMENT

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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MUSCULOSKELETAL MANAGEMENT

pain, medicated, AROM exercises, PROM, Assisted with flexion/extention, abduction/adduction, tolerated,

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OXYGEN MANAGEMENT

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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PAIN MANAGEMENT

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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WOUND MANAGEMENT

medicated, intact blister, drainage, serous fluid, Skin red, warm, intact, Applied..ordered, Patient tol,

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PATIENT TEACHING

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

___ is a basic physiologic need. Failure to meet this need will subject the patient to a number of complications, including ____ ,____, and ____. Any of the preceding conditions would lengthen the patients hospital stay and delay the recovery process.

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Created by: chel4u84