Mnemonics Flashcards
Caring
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.
Asepsis
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
DocumentMobility
MAD ATOP
Mobility status-full? Partial? Abnormalities with gait? Devices-does pt use a knee brace, walker, cane? Ambulate Turn Offload Position
Fluid management
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?
Abdominal Assessment
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
TendernessNeurological Assessment
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
Peripheral Neurovascular Assessment
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
Respiratory assessment
PAIR Position the patient(upright) Assess the RRAP-rhythm, rate, accessory muscle use, and pattern Instruct to deep breath Record
Skin Assessment
TIME to check Color of skin You have to pick 2 vunerable skin surfaces-easy(occiput, tronchanter, heels, sacrum Temperature Integrity Moisture Edema Color
Management areas of care
AIR
Assess Implement Reassess
Comfort Management
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
Musculoskeletal Management
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
Oxygen Management
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
Pain management
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
Respiratory management
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
Wound Management
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
Drainage collection and specimen collection
COCA RAT needs Cleaning Color Odor Consistency Appearance Record Amount Type Cleaning-document if you clean the surrounding skin and or tissue
Enteral feeding
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
Irrigation/installation
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
Maintenance of intermittent venous access device
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
Medications
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
Pt teaching
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?
