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
