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CPNE > Mnemonics > Flashcards

Mnemonics Flashcards

0
Q

Caring

A

In Every Team Performance, Everyone Vaules Confidence-IETPEVC

Introduce/ID patient
Explain purpose of interaction
Therapeutic Touch/Communication
     Encourage pts expressions of  
     needs
     Facilitate goal directed interactions
       Ask questions for pts response to 
       care
       Always speak to the patient and
       explain what you are about to do
       Take pts choices into account
           Ask what would you like me to 
           do first?
        Determine pts comfort level
Physical expression
Verbal expressions
     Body language=verbal
Cultural awareness
     Address adult by Mr or Mrs.
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1
Q

Asepsis

A 
Have Policies Determining Sterility
Hand Hygiene
     At start of implementation phase
     Before and after direct contact with    
     patients, wearing gloves
     Before leaving the patients room
     If moving from a contaminated body 
     to a clean body site
Protects from contamination
     Turn faucet off with barrier(paper)
     Avoid touching clothing with soiled
     items
     Do not place any items on floors
     Return moved objects to original
     place
     Pour liquids directly into drain(toilet)
     Place PCS form in your pocket
  Protect the patient
     PPE
Disposes of contaminated materials
     In designated containers
Establishes a sterile field when required
      Hand hygiene, PPE, ID pt, select 
      Area waist high, open sterile 
     wrapped drape
      Document
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2
Q

Mobility

A

MAD ATOP

Mobility status-full? Partial?
Abnormalities with gait?
Devices-does pt use a knee brace, walker, cane?
Ambulate
Turn
Offload
Position
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3
Q

Fluid management

A

Have I Drank Something?

Hydration status-check turgor, mucous membranes, or anterior fontanel if pt is <1(must assess upright)
Ins and outs
Drip rate-20 minutes
Site check-is site warm? Edema?

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4
Q

Abdominal Assessment

A 
PPP, look, listen, feel,-DART
Pee?-does the patient have to urinate before the exam?
Pain? Does the patient have pain
Position-flat with knees flexed
     If can't tolerate then elevate bed to      
     Less than 30 degrees
Look
Listen
Feel-all 4 quadrants
Distended Abdomen
Rigidity
Tenderness
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5
Q

Neurological Assessment

A

LAMP
LOC-person, place, time
Assess fontanel(less than 1)-bulging? depressed?
Movement-hand grasp/push down and up and pedal push/pull
PERL-pupils equal and reactive to light

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6
Q

Peripheral Neurovascular Assessment

A

Please Make Sure To Check Cap refill
Pulses-find most distal pulses and palpate both at same time and compare to each other
Movement-ask the pt to move extremities or noting movement in child<3 or in a non-communicating adult
Sensation-did the pt feel it when you squeezed their hand/foot? (Eyes closed)
Temperature
Color or Cap refill

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7
Q

Respiratory assessment

A 
PAIR
Position the patient(upright)
Assess the RRAP-rhythm, rate, accessory muscle use, and pattern
Instruct to deep breath
Record
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8
Q

Skin Assessment

A 
TIME to check Color of skin
You have to pick 2 vunerable skin surfaces-easy(occiput, tronchanter, heels, sacrum
Temperature
Integrity
Moisture
Edema
Color
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9
Q

Management areas of care

A

AIR

Assess Implement Reassess

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10
Q

Comfort Management

A 
COMFORTERS
Assess comfort needs-ask the patient questions that describe their comfort needs
Comfort measures-do 3
Observe for discomfort
Meds PRN
Face wash
Oral care
Relaxation
Treat with heat or cold(if assigned)
Evaluate comfort at end
Reposition
Simple back rub
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11
Q

Musculoskeletal Management

A

MAP HATR
Mobility status-full? Partial?
Abnormalities-with gait?
Pain with movement?
Heat or cold(if assigned) 20 minutes
Apply devices(knee brace ie) if needed
Traction-make sure lines are unobstructed and weights hang free(if needed)
Range of motion-examiner will state if you have to
Passive or active-upper or lower, one or both

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12
Q

Oxygen Management

A

SOAP
Skin assessment-check skin around cannula, face mask. Intact?,Red?
Oxygen status-O2 sats, OR cap refill
Activity level-assess pts response to activity. Tired? SOB?
Position-position to help facilitate breathing

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13
Q

Pain management

A

Assess PRN
Assess location, duration, and description of pts pain
Location- where have pt point to it or say where it is
Duration-how long have you had it? How long does each episode last
Description-sharp or dull
Pain scale-0-10/FACES/FLACC tool
Reposition, relaxation-reminder to do something for pain-back rub, hot/cold(if assigned), pain med
Need to reassess-did pain level go down, did intervention work

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14
Q

Respiratory management

A 
HAIR
Must do respiratory assessment mnemonic first then HAIR assessment
How did pt tolerate deep breathing
Always perform deep breathing and cough
Incentive spirometry(if assigned)
Reassess after deep breathing/cough/ICS
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15
Q

Wound Management

A

TIGR open. Gloves soaked? Clean gloves. PAT dry

Record when done
SALAD
Stage of wound(what kind of wound is it)
Appearance of wound
Location
Actions implemented and how much the patient screamed(complaints of tenderness during tx)
Drainage-sanguinous(bloody), serous(clear) sero-sanguinous, purulent

16
Q

Drainage collection and specimen collection

A 
COCA RAT needs Cleaning
Color
Odor
Consistency
Appearance
Record
Amount
Type
Cleaning-document if you clean the surrounding skin and or tissue
17
Q

Enteral feeding

A 
RAT FEVER
Record
Amount of formula and 
Type of formula
Fowlers-position in fowlers first to receive the tube feeding
Examine gastric tube/abdomen
Verify gastric residual amount by aspiration and then re-instill
Expiration date of formula
Record rate in 20 minutes

Burp infant under 6 months of age
If residual is greater than 30 ask if tube feeding should be held

18
Q

Irrigation/installation

A 
PRI RAT
Position patient
Recepticle placed for returned flow of instilled fluid
Instill fluid
Record
Amount of solution used
Type of solution used
Make sure fluid is room temp
19
Q

Maintenance of intermittent venous access device

A 
IAAF(similar to fire fighters union)
Assess insertion site for dislocation, infiltration
  Feel for temp changes
  Palpate for edema
Aspirate for blood return
Record amount of irrigating solution
Record flush solution
Record/Response
20
Q

Medications

A

MARS
Mar check and 6 rights
Allergies? Apical pulse?(specific to med you are passing)
Recheck Mar/kardex to pts ID band
Sign MAR form
IV med
IV med station (clean label clean) or I Glove I Glove

21
Q

Pt teaching

A

RID
Readiness to learn-is this a good time to talk about
ID pts learning needs-what do you know about xyz
Does pt understand? What can you tell me about what we just talked about?

CPNE (1 decks)

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