Mnemonics Flashcards
Abdominal Assessment (No education needed)
PPP, Look, Listen, Feel, DART Distended Appearance Resistance of muscles Tenderness
Picture a man with eyes/ears/hands (look/listen/feel) on his abdomen and throwing a DART
Comfort Management
RID, CAR (Driving in a super comfortable car)
C: Check comfort level (daisies, verbal(1-10) or observed behavior)
A: ask patient and/or nurse what makes patient more comfortable
R: Reassess if interventions improved comfort
*must perform 2 interventions
Fluid Management - Enteral (g-tube, ng-tube)
Fluid Management - Oral
(Brat baby hooked up to an iv pole throwing his bottle)
Up the arm, down the arm, BRAT FEVERR HEL
B: Burp infants
R: Record
A: Amount/Rate and
T: Type of fluid (20 minute documentation required)
F: Fowlers Position E: Examine G-tube and adjacent area V: verify residual, measure, reinstill if indicated E: Expiration Date R: Room Temperature R: Response of patient
H: hydration status
E: education provided
L: learner understanding
Fluid Management - intake/output
HELP, color, time H: Hydration status E: Education provided L: Learners understanding of education provided P: Patients response Color of all output Time measured
*I/O’s - empty water pitcher and refill with known quantity and have pt. count how many cups they consumed during PCS.
Fluid Management - Parenteral (IV)
20 minute check: site/dressing check, solution, flow rate, system integrity
Up the arm, down the arm, HELP H: hydration status E: Education provided L: learner understanding of education provided P: Pt.'s response
Fluid Management - Drainage
20 min. Check
RID
DR SCAT
(A doctor full of bullet holes and draining everywhere)
D: dressing
R: response to device (discomfort, pain, etc.)
S: Skin
C: Color of drainage
A: Amount
T: Type (of drainage and device)
Medications
MISTER ARCS
(Old man patient in bed who is grumpy and always refuses meds)
M: MAR check
I: Inspect site
S: Site of vitals
T: Tell examiner if you’re giving or holding med
E: Educate the patient, evaluate learning
R: Recheck MAR to ID band and administer med
A: After administration
R: response of patient?
C: Condition of IV site before leaving?
S: Sign and fill out MAR
Musculoskeletal Management
RID, Fall, CAN PAMS HARDAR
(Female body builder with can falling on bicep)
Fall: Morse Fall Scale
C: Call Bell (pt. Must demonstrate proper use)
A: Alarms in tact and functioning
N: Non-skid socks
P: Pain of extremities with movement
A: Appearance of extremity (joints, skin, etc)
M: Mobility of joints (e.g. Full, partial)
S: Strength of extremity
H: Heat or cold - 15 mins. Max
A: Activities performed
R: ROM - flexion/extension, abduction/adduction, pronation/supination (2 movements per joint x2 repetitions)
D: Devices: walker, cane, etc.
A: Alignment (document pt. kept in proper alignment throughout Care)
R: Response of patient to Activities
*support joints when doing passive ROM
Neurological Assessment
Level LAMP (Level lamp above mans head)
Level of arousal (verbal, tactile, painful)
L: LOC to PPT
A: Assess anterior fontanelle
M: movement - grips/push-pulls (symmetry upper and lower for under 3 years old)
P: PERL (must document brisk, sluggish, fixed)(must notify CE you are ready to assess pupils and darken the room)(instruct pt. To look into the distance)
Oxygen Management
RID, SOAP (20 min. Check - verbalized O2 rate/delivery method)
(Soapy tire)
S: Safety and Skin around delivery system (pad/lotion as needed) (no fire hazards or petroleum lubricants)
O: Oxygen Staus: COORS
C: Color: name beds, lips, mucous membranes
O: oxygen LPM
O: O2 sats
R: Respiratory effort
S: Signs of fatigue
A: Activity - response to activity during PCS
P: Position patient to help facilitate breathing
Peripheral neurovascular management
RID, Please Make Sure To Check, Cap refill, Edema, and Circulation after a WASP stings you. (PMST, cap refill, edema, WASP) P: Pulses (bilateral, simultaneous) M: movement (wiggle toes or fingers) S: Sensation T: Temp C: Color
Cap Refill
Edema
*Interventions* W: Warmth A: Activity/exercise S: Stockings/SCD's P: Position (legs up for venous NOT arterial)
Respiratory Management
RID, PAIR OR REASSESS PACCOS Secretions
P: Position for auscultation
A: assess RRED
I: instruct to take slow deep breaths
R: Receptacle (for spitting)
O: O2 sats (before, during, after)
R: Respiratory Hygiene
1. Cough after 3 deep breaths
2. Incentive spirometry/pinwheels/bubbles
3. Tracheal suctioning/Oral suctioning
4. Oral care (mouthwash, rinse, brush)
Reassess: RRED
*if secretions* P: presence/absence (before and after interventions) A: amount C: color C: consistency O: odor S: secretions
Tracheal Suctioning
ESA GOSTS with Saline HIDRO - Reassess
(Ghost with saline bottle being dumped over him)
E: Explain procedure to patient
S: Semi Fowlers
A: assess RRED
G: Gown & Face shield
O: O2 Sats (before/during/after)
S: Set suction (infant-50, child-100, adult-150)
T: trach kit (5-8 infant, 8-10 child, 12-18 adult
S: Sterile gloves (dominant hand stays sterile)
Saline: lubricate and verify patency
H: Hyper-oxygenate (1-2 minutes at prescribed LPM)
I: insert cath no more than 6” and rotate while removing
D: deep breathing after each suctioning
R: Repeat after 30 seconds if indicated/ordered
O: Oral Care
Reassess: RRED and O2 sats
Oral Suctioning
ESA GOSSIP, Repeat, Oral, Reassess
E: explain procedure to patient
S: Semi-fowlers
A: assess RRED
G: Gown, gloves, face-shield O: O2 says (before/during/after) S: Set suction (infant 50, child 100, adult 150) S: Saline (lubricate and verify patency) I: Insert Yankauer P: Perform deep breathing
Repeat: after 30 seconds if needed/ordered
Oral: mouth care
Reassess: RRED and O2 sats
Skin Management
*must pick 1 vulnerable area to assess (must check both sides if it is a bilateral part)(occiput, heels, sacrum)
*must perform 2 interventions
RID, P.S. it’s TIME to check Color changes and Turgor
PS,TIME,color changes,Turgor
PS: Pressure scale (Braden) T: Temp I: integrity of skin M: Moisture E: Edema Color Changes Turgor
