for the 15th and 16th editon of excelsior CPNE
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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| 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
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| I CARE | introduce/ID w/kardex choices given always listen respond to pt explain purpose
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| 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
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| VITAL SIGNS | get baseline position properly no >30mm doc/declare take x2
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| WASH | wash hands 30 secs always dispose sterile field hands gloved
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| SCAB | side rails up/slippers on call bell/phone in reach ask needs/assess for pain bed in low/locked position
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| REALITY | respect evaluate comfort acceptable language interaction touch yak
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| MAD ATOP | mobility status abnormalities devices (knee brace,walker,cane) ambulate turn offload position DO 1
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| 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
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| 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
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| 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
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| PAIR | positon upright assess the RRAP(rate rhythm accessory muscle use pattern) instruct deep breathing/listen on skin upper/lower bil record
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| TIME 2 CC | temperature: warm/cool integrity:x2 rash,lesions, color changes,intact moisture: moist/dry edema: present/absent color cap refill
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| 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
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| MAP HATR | mobility status abnormalities pain w/movement heat/cold apply devices traction:lines free wts free range of motion active/passive
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| SOAP | skin assessment near o2 device o2 status: o2 sat,clubbing,cap refill color activity level: tired, SOB? position upright
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| PAIN | pain scale assess comfort intervention:reposition, pain med,back rub,distraction,heat/cold,report to nurse need to reassess/record data
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| 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
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| WOUND | wound drainage assessment(loc,appearance type) observe site unique sol(temp, delivery receptacle) need sterile field dressing
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| 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
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| 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
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| 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
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| 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
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| 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?
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| 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
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| 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
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| 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
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| 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
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| 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
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| RESPIRATORY MANAGEMENT-AOC | nd-ineffective airway clearance pt will achieve comfortable pulmonary function during my pcs
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| MUSCULOSKELETAL MANAGEMENT-AOC | nd- impaired physical mobility pt will increase mobility during my pcs
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| PAIN MANAGEMENT-AOC | nd-acute pain pt will verbilize acceptable pain level during my pcs
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| COMFORT MANAGEMENT-AOC | nd-readiness for enhanced comfort pt will verbalize acceptable comfort level during my pcs
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| OXYGEN MANAGEMENT-AOC | nd- activity intolerance pt will tolerate activity without excessive fatigue during my pcs
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| WOUND MANAGEMENT-AOC | nd-impaired skin integrity
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| POTENTIAL DX | risk for falls>65 r/t unfamiliar environment pt will remain injury free during my pcs
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