Enter

Fluid Management Hydration Enteral (offer if encourage fluid)

WIP

V/S Compare T (O, ax, temporal, tympanic) P (radial, apical) R B/P (manual, automatic) Wt (balance scale, barrier, undress, Prior to eating/feeding) O2 sat Pain level (SHOW CE) NEURO Assessment WIP Consciousness x 3 (or observe/stimulate) Anterior Fontanel (if app) PERL Equality Stimuli

Wash

Mobility WIP Moves (equally, freely, no difficulty) ABN balance Devices (walker, abductor pillow) Ambulate/Align Transfer/turn/lift Position w/ support Observe gait/balance Pt response Safety (Stabilize equipment, footwear) PVA WIP Palpate pulses Compare bilaterally Perfusion (color or cap RF) Temperature Tactile stimulation Motor movement

ntro

Parenteral w/ Kardex (fluid,rate,tubes) Assess site w/ gloves Regulate rate Record fluids infusing (note volume) I&O Need to reassess volume (SHOW CE) ABD Assessment WIP Pee, position, pain Sx off ~ on Look Listen Glove (if app) Feel

Need? (Caring) Comfort/sleep well?

20 Minute Checks

W=wash, I=ID, P=privacy

MEDs WIP

MARMedExpiration

Appropriate Dose

Recheck MAR w/ ID

Do 5 rights

Observe allergies

Special Assessments (b/p, pulse, bruising, bleeding pain level)

Ask how takes?

Gather supplies

Evaluate/administer

Sign MAR

RESP Assessment WIP

Skin Assessment WIP 2 areas Moisture Edema Temperature Integrity Color

Comfort Management WIP Comfort level Oral care Medication Bed linens Heat/cold (if assigned) Environment Reposition Distraction Backrub Ask mom (toy, feed, diaper, pacifier) Wash cloth Record Response

Exit Down bed/brakes Evaluate need Side rails up I&O Remember call light Evaluate comfort Sanitize

Position

Rhythm/rate/pattern

Equipment

Ascultate bilaterally

Tell pt breath deep/slow

Hear ABN/NORM

O2 Sat

Other AOCs O2 Mgmt WIP Activity tolerance Oxygen administered Nail bed color/cap RF or O2 sat Skin around tubes Position Humidification Equipment (set/maintain) Record response Pain Mgmt Pain level Assess location, characteristics, duration Implement X 3 Need to reassess after 30 min Record response RESP Mgmt WIP Position Rhythm/rate/pattern Equipment Ascultate bilaterally Tell pt breath deep/slow Hear ABN/NORM O2 sat Gloves Emesis Resp. hygiene & Reassess

MUSC Mgmt WIP

ABN

Mobility

Pain w/ movement

Traction

ROM

Assess response

Supportive/therapeutic devices

Heat/cold if assigned (barrier, x 20 min,

Record response

ight temperature)

Pillow (splint) if app Sx <15 secs

Wound Mgmt WIP

Drainage Specimen Amount Container Color Obtain

WIP

Enteral Continous Intermittent Id Type Position Exp Label Verify feeding Strength Flow Rate NG tube Placement & residual ID Tubing (kinks, etc.) Volume (note) Placement Residual

WIP

Irrigation WIP Type Temperature Amount Placement (pt & receptacle) Tube placement In correct area Rate Record Device

Wound drainage

Observe type, appearance, location

Unique cleanser/irrigant:Receptacle

Away

Remove tube (assigned) Skin around (assigned) Record Patency Gravity

Protect skin

In correct cavity (assigned) Transport

Need pack/topical?

Dressing-date, time, initials

Record response

Position

I&0

Patient Teaching

Learning readiness

Evaluate need

Accurate info

Reassess understanding

Need to document