Mnemonics For Assessments Flashcards
Respiratory Assessment
BREATHER BAD
Best position - upright Respect privacy Explain procedure (slow deep breaths) Assess deep breathing and accessory muscles Timing (breathing pattern) Hear (on skin in 4 spots) Evaluate O2 (only if assigned) Record findings Breath sounds bilaterally Abnormalities found? Desats
Respiratory Assessment
U BREATHE
Upright position Breathing pattern Rhythm/rate Equipment (stethoscope/pillow) Auscultate (posteriorly on skin) Through nose & out of mouth (breathe slowly and deeply) Hear in 4 spots (anteriorly or posteriorly) Evaluate & record
Peripheral Neurovascular Assessment
BLOOD FLOW
Bilaterally Look at color Or capillary refill Observe for sensation bilaterally Doppler if can't find pulses Feel for most distal pulses Look for movement Observe temperature Write it down
Peripheral Neurovascular Assessment
PERIPH
Pulses (bilaterally) Extremity (designated upper or lower) Refill (capillary) Is there sensation with eyes closed/movement Pale/pink Hot/cold (temp of skin)
Abdominal Assessment
4Ps LLFs RR
Privacy Pee Pain Position Suction off Look Listen Feel Suction back on Reposition Record
Neurological Assessment
LOGICSS
LOC (person, place, time)
Observe pupils
Grasp hands
Inspect fontanel (anterior and upright in 1 year old)
Check dorsi/plantar flexion
Stimuli (noxious for unconscious patient)
Symmetry of movement (child under 2 only)
Skin Assessment
SKINNED
Skin color Keep warm and dry Intact/integrity Note edema Need repositioning Evaluate pain Do 2 areas
Skin Assessment
Areas to assess for skin assessment
A SHEETS
Anal Skin folds Head Ears Elbows Trochanters Sacral/coccygeal
Skin Assessment
TWICED RED
Temperature Wet/dry Intact/integrity Color Edema Reposition Evaluate pain Do 2 areas
Respiratory Management
BREATHE EASIER
Breathing pattern
Rhythm and rate
Explain procedure, get equipment (stethoscope and pillow)
Assess deep breathing and
Accessory muscles
Timing - breathing pattern (tell to breath slow & deep)
Hear - posteriorly on skin in 4 locations
Evaluate O2 (if assigned)
Emesis basin
Assess breathing
Suction (if assigned)
Incentive spirometer or deep breath & cough
Evaluate again
Record
Comfort Management
A 3rd CHANCER
Assess comfort level 3 comfort measures Reposition Dental hygiene Cold/heat Hygiene (face & hands) Arrange linens NSAIDs, or other symptomatic meds (itching, nausea, etc.) Comfort rub Environmental adjustments Record (evaluation/measures/re-evaluations)
Pain Management
PAINED MGMTT
Pain scale (FLACC, Faces, 0-10 verbal) Assess location of pain Intensity and description of pain Need to reassess (20-30 minutes after implementation) Exacerbation Duration (when did it start? How long it lasts?) Massage Guide or distract Medication Turn (reposition) Temp (heat, cold with barrier) (only when assigned) *pick 3 of the pain managements to do*
Pain Management
COLDERRA PP
Character Onset Location Duration Exacerbation Radiation Relief Associated symptoms Pain scale Pick 3 pain relief measures
Pain Management
PAIN 123
Pain scale Assess comfort Interventions (do 3) Need to reassess after implementation 1 - pain level 2 - relief measure 3 - patients response
Musculoskeletal Management
MAD PART
Mobility status Abnormalities Devices and balance Pain Apply heat/cold Range of motion Traction
Wound Management
WOUNDED
Wound location Observe drainage/type/amount Unique irrigation and supplies Need clean or sterile field? Dressing change Evaluate pain/tolerance Document (What you did, the findings, and tolerance)
Oxygen Management
SHORT AIR
Sats (if assigned) Humidity (if ordered) Observe (ears/nares) Reposition up Tolerance to activity Amount of O2 Ignition sources Report (color,clubbing)
Oxygen Management
BREATHE SAFER
Best position Response to activity Ears and nares Assess color, cap refill, clubbing Triggers to combustion Humidity Evaluate Sats (if assigned) Assess tolerance Finally Evaluate & Record
Oxygen Management
STOP COPD
Set O2 rate Temp/humidity Observe color/clubbing Prevent sparks Color/condition of skin O2 Sats Position/tolerance Document
Specimen Collection
COLD TACT
Collect Observe (color, odor, etc.) Label (initial, date, time) Document Type Amount Color Tolerance
Specimen Collection
SPECIAL
Specimen collected Place tube Examine (color, odor, etc.) Clean surrounding area I&O record Assess site Label and send to lab
Enteral Feedings
FLOW STOMACH R&R
Feeding type Low Fowlers Orient patient Warmth of solution (room temp) Select device Total amount On time Monitor feeding during PCS Assess skin around NG/G Tube Check residual (when assigned) Have a baby burp Reassess Record
Enteral Feedings
DROP ATT
Device Room temp Orient patient Position Amount Type Time
Irrigation
STOP FLOW
Solution Temperature (room temp) Other equipment (chux, receptacle, gloves) Position to facilitate drainage Flow rate (slow and gentle) Look at return solution (amount & color change) Observe patient's tolerance Write it down
Medications
MAR DOSAGES
MAR check meds Appropriate dose Recheck MAR to ID Do 5 rights Observe allergies Special assessment (BP, pulse) Ask how patient takes pills (one at a time or all at once) Gather equipment Evaluate and administer Sign MAR
