MNEUMONICS Flashcards
Nursing Process (AA(D)PIE)
Assessment Analysis (Diagnosis) Planning Implementation Evaluation
Critical Elements for the Planning Phase (212 Rule)
(2) NANDA Labels (relevant to assigned patient within last 24 hours, overriding, required, selected AOC that is on your kardex or in critical elements.
(1) Outcome for each (clear, concise, and measureable)
(2) Validation assessments for each
“1st in Room” (EKWIIG)
Knock on door Enter room Wash Hands Introduce Self Id Patient Gloves
Vital Signs
Temperature Apical Pule Respiration Rate Blood Pressure Manual Oxygen Saturation Weight Pain (*2 set, compare and contrast)
Mobility (MOBILE)
Movements (mobility level) Observe Alignment Balance and Devices Increase support (interventions) Log response Evaluate *SKID SOCKS ON *CHECK CARE CARD *CHECK TRANSFER STATUS *GAIT BELT *LEAVE ON TOILET ALONE?
Mobility NANDA
Impaired bed mobility
Impaired transfer ability
Impaired physical mobility
Patient Teaching NANDA
Deficit Knowledge
SHEEP (implementation phase)
Supplies (gather necessary equipment) Hygiene (wash hands) Explain (procedure) Expose (necessary areas) Proper temp (environment of room and equipment)
Abdominal Assessment (4Ps LLFs RR)
Privacy Pee Pain Position Sx off Look (flat, round, distended, etc.) Listen Feel (tenderness, pain, rigid, etc.) Sx on Reposition Record LLF
Abdominal Assessment (NANDA)
Dysfunctional GI motility
Constipation
Nausea
Neurological Assessment (E-LOGICSS)
Environment (dim the lights) LOC (person, place, and time) Observe pupils (pearl and pen light) Grasp hands bilaterally Inspect fontanel anteriorly and upright Check dorsi/plantar flexion Stimulus (noxious for unconscious pt (verbal or tactile)) Symmetry of movement (child)
*CHILD MUST BE UPRIGHT (1 YEARS) P-pupils E-equal A-and R-reactive to L-light
Neurological Assessment (NANDA)
Acute confusion
Comfort Management (A 3rd CHANCER)
Assess comfort Level (comfort scale) 3 comfort measures Re-position Dental Hygiene, distraction, relaxation cold/heat (when assigned) Hygiene (face, hands) Arrange Linens NSAIDS, other symptomatic meds (itching, nausea, etc.) (comfort rub) Environmental Adjustments Record (evaluation, measure, re-evaluate)
Comfort Management (NANDA)
Impaired Comfort
20 Minute Check (CHIPPICO3WS)
Communicate
Hydration Status (turgor, mucous membrane, fontanel)
IV (rate, amount, type)
Palpate site (with gloves)
Pump (settings, gtts)
Inspect IV tubing (kinks, bubbles)
Check enteral fluids (site, rate, amount)
Oral Fluids explain, Other drains, O2
Write down findings
*Skid socks on
*Let patient know you are in charge of intake and output
Fluid Management
Hydration status
Musculoskeletal Management (RAM SAMS PART)
Readiness to Learn Assigned Areas (check appearance, strength, mobility) Morse Fall Scale (fill out) Strength Any devices Mobility of Joints, appearance, abnormal Symptoms with movements (pain, stiffness) Place barrier Apply heat/cold (when assigned) ROM (when assigned) 2 repetitions
Musculoskeletal Management (NANDA) (DAVIT PMU)
- Impaired Physical Mobility r/t musculoskeletal impairment or tissue trauma AEB unsteady gait
- Impaired bed mobility r/t musculoskeletal impairment AEB inability to re position self in bed.
- Activity intolerance r/t deconditioning or tissue trauma or prolonged immobility AEB SOB on exertion or verbal c/o weakness
Oxygen Management (R PASS CC SAFER)
Readiness to Learn Position upright Amount of O2 (verify) Sats (O2 before and after) Safety (ignition, tubing) Color Clubbing of Fingers? Skin integrity (ears, nares, face, lips) Activity intolerance (SOB on excertion) Flow of humidity Effort of breathing (SOB, gasping, work) Reassess SPO2, Respiratory rate and Record
Oxygen Management (NANDA)
- Impaired gas exchange r/t ventilation, perfusion imbalance between O2 supply and demand
- Ineffective breathing pattern r/t pain or tissues trauma
- Activity intolerance r/t COPD
Peripheral Neurovascular Management (R PERIPH ME HOT MESSED)
Readiness to learn
Pulses (bilaterally)
Extremity
Refill (capillary)
Is sensation
Pale/Pink
Hot/Cold
Motor function
Edema
Help Perfusion by:
-Offering blanket
-2 interventions
-Movement/reposition
-Exercise
-Stockings (TEDS)
-SVDS
-Evaluate
-Document
Peripheral Neurovascular Management (NANDA)
-Ineffective peripheral Tissue Perfusion
Respiratory Management (NANDA)
- Ineffective airway clearance
- Ineffective breathing pattern
- Impaired gas exchange
Skin Management (BRADEN R SKINNED OPARKA) *2 areas to assess*
Braden Scale Readiness to learn Skin color Keep warm/dry (check temp) Integrity intact Note Edema Need repositioned Evaluate pain Do 1 Observe turgor Provide incontinent Care Apply maintain devices Reposition Keep skin Clean Apply protective barrier
Skin Management (NANDA) Wound Management (NANDA)
- Impaired tissues integrity
- Impaired skin integrity (epidermis and dermis)
Wound Management (OUCH WOUNDED SKIN)
Observe behavior
u ready (readiness to learn)
Check pain (scale, observe behavior)
Have nurse medicate prior
Wound location
Observe drainage,type, appearance
Unique irrigation, supplies, and position of pt
Need clean or sterile
Dressing check (present? Intact? Drainage?), then /\
Evaluate pain and tolerance (before, during and after)
Dispose in appropriate receptacle
Secure dressing
keep skin, clothes, linen dry
Initial, date and time
Note
-(AIR)
*assessment
*intervention
*responseCRYS (pediatric exit)
Crib rails up
Reach (infant/child in reach while SR down)
You see (infant insight during care)
Secure infant/child when OOB in seat
Care Plans (Related to Factor)
Can be a DX
Can not be surgical procedure, procedure, Person placement, or gt/ng/PICC
Care Plans (Interventions)
No assessments
Must be patient centered and specific
Must move patient toward outcome
(If I do this,________(intervention) will this help the patient move toward the_________(outcome)?
Care Plans (Defining Characteristics)
(pg 90)
Assessment #1 and #2 (signs and symp)
Check mosby’s
Abdominal Assessment Documentation
DAC BTM
Document: Appearance of Abdomen Contour of abdomen Bowel sounds in all quadrants Tenderness or pain Muscles resistance
Comfort Management Documentation
DELC CPCR
Document: Education Provided Learner understanding of education provided Comfort Assessment method Comfort assessment prior to intervention Patient preferences for comfort needs Comfort intervention implemented Reassessment of comfort after interventions
RUBBERSS**RR
Readiness to learn
Up right position
Bare skin (4 areas –>
Fluid Management Documentation (General)
{DHEL}
Document
Hydration Status
Education Provided
Learns understanding of education provided
Fluid Management Documentation (Continuous Enteral Feeding)
{DWFIVTIAAP}
Document
Within 20 minutes after start of implementation
Feeding formula and rate
Integrity of system
Volume of (ml) of enteral feeding during PCS w/i 10% +/- of actual intake during planning and implementation
Indicate time of measurement
Place initials in appropriate box on Fluid Mgmt Flow sheet
Amount of gastric residual
Amount of gastric residual reinstilled
Patient response to feeding
Fluid Mgmt Documentation (Bolus Enteral Feedings)
Document Feeding Formula Flow rate Integrity of system Appearance of skin surrounding entry site Volume (ml) of enteral feeding during PCS within +/- 10% of actual intake during implementation Amount of gastric residual Amount of gastric residual reinstilled Patient response to feeding
Fluid Mgmt Documentation (Oral enteral Fluids)
{DTAP}
Document on fluid sheet
Type of enteral fluid intake, in (ml) (water, milk,enfaml)
Amount of each enteral fluid in, (ml) or time (10 minutes each breast) within 10% of actual intake during implementation
Patient response to feeding
Fluid Mgmt Documentation (Parenteral Fluids)
Document on flow sheet within 20 minutes of implementation
Iv Solution, flow rate, condition of IV insertion site
(If solution changed, New IV solution, flow rate for new solution, condition of IV insertions site prior to start of new IV solution)
Volume (ml) of parenteral intake during PCS w/I 10% of actual intake during planning and implementation
Indicate time of measurement
Place initials in appropriate box on fluid mgmt. flow sheet
Patient response to parenteral intake
Fluid Mgmt Documentation (Intermittent Access Device)
{DCTAP}
Document Condition of insertion site Type of flush Amount of flush (ml) Patient response to flush
Fluid Mgmt Documentation (Drainage Devices)
Document
Type of drainage device
Site of drainage device
Type of suction
Amount of suction
Integrity of system
Condition of skin surrounding insertion site
Drainage type
Drainage color
Drainage amount (ml) w/I 10% of actual output during planning and implementation
Indicate time of measurement
Place initials in appropriate box on fluid mgmt. sheet
color of output
Patient response to drainage device
Patient response to removal of drainage device (if assigned)
Musculoskeletal Mgmt Documentation
DELMMANP
Document
Education provided
Learners understanding of education provided
Morse Fall scale score
Morse fall scale risk level (no risk, low risk, high risk)
Assessment data for assigned extremities (appearance, muscle strength, joint mobility, symptoms)
Nursing interventions implemented (fall prevention, range of motion, therapeutic devices, application of heat/cold, body alignment, positioning/activity)
Patient response to interventions implemented
Neurological Assessment (Documentation)
Document
Level of arousal
Level or orientation
Characteristics of anterior fontanel when indicated
Equality of pupil size
Pupil reaction to light
Equality of muscle strength in upper extremities
Equality of muscle strength in lower extremities
Equality of motor response in upper extremities
Equality of motor response in lower extremities
Oxygen Mgmt (Documentation)
Document
Education provided
Learners understanding of education provided
Condition of surfaces affected by O2 delivery system
O2 delivery rate
O2 delivery method
O2 saturation level before interventions
O2 saturations level after interventions
Respiratory changes associated with activity during PCS
Nursing intervention to facilitate oxygenation implemented
Nursing intervention to prevent alterations/maintain integrity of surfaces
Patient response to interventions Implemented
Peripheral Neurovascular Mgmt (Documentation)
Document
Education provided
Learners understanding of education provided
Assessment data of bilateral comparison of the most distal area of the assigned extremities (color, capillary refill, motor function, sensation, temperature, pulse location, pulse quality, edema)
Interventions implemented for peripheral Neurovascular mgmt.
Patient response to interventions implementedtio
Respiratory Mgmt (Documentation)
Document
Education Provided
Learners understanding of education provided
Assessments before intervention (respiratory status, Respiratory rate +/- 2 respirations/minute for patients 2 years or older or +/- 6 respirations/minute for patients under 2 years) (respiratory depth, respiratory rhythm, respiratory effort)
Breath sounds in bilateral upper and lower lung fields
O2 saturation level to exact percentage (O2 delivery rate, O2 delivery method)
Presence or absence of secretions
Respiratory hygiene interventions implemented
Evaluation after interventions:
Abdominal Assessment Documentation (Sample Note)
Abdominal Assessment completed. Abdomen noted to be flat, with no distention. Skin intact, no discoloration present. Upon auscultation of abdomen, bowel sounds present in all four quadrants (hypo/active/hyper). Palpation of abdomen with no pain or tenderness voiced. Abdomen soft with no resistance or rigidity noted.
Comfort Management Documentation (Sample Note)
Comfort assessed, patient verbally rates comfort as a 1 out of 10 on the comfort verbal rating scale. The patient states “I do not know how I can move myself since I have had hip surgery.” Head placed on pillow, patient positioned on right side with abductor pillow adjusted between knees. Offered an ice pack to the hip and patient was agreeable. Patient educated regarding proper body alignment, the purpose of the abductor pillow, the ice pack, and the length of time it is applied. Informed patient to request it as needed. Post interventions, patient stated comfort was 8 out of 10 on the comfort verbal rating scale. Patient able to state “I am keeping my body in proper alignment makes me feel better, the abductor pillow will support the muscles in my hip and the ice pack will remain in place for 20 minutes at a time.” Patient also states “I can use my arm to move myself in bed.”
