Enter Wash Intro ID Need? (Caring) Comfort/sleep well?
20 Minute Checks W=wash, I=ID, P=privacy
Fluid Management Hydration Enteral (offer if encourage fluid)
WIP
V/S Compare T (O, ax, temporal, tympanic) P (radial, apical) R B/P (manual, automatic) Wt (balance scale, barrier, undress, Prior to eating/feeding) O2 sat Pain level (SHOW CE) NEURO Assessment WIP Consciousness x 3 (or observe/stimulate) Anterior Fontanel (if app) PERL Equality Stimuli
Mobility WIP Moves (equally, freely, no difficulty) ABN balance Devices (walker, abductor pillow) Ambulate/Align Transfer/turn/lift Position w/ support Observe gait/balance Pt response Safety (Stabilize equipment, footwear) PVA WIP Palpate pulses Compare bilaterally Perfusion (color or cap RF) Temperature Tactile stimulation Motor movement
Parenteral w/ Kardex (fluid,rate,tubes) Assess site w/ gloves Regulate rate Record fluids infusing (note volume) I&O Need to reassess volume (SHOW CE)
MEDs WIP MARMedExpiration Appropriate Dose Recheck MAR w/ ID Do 5 rights Observe allergies Special Assessments (b/p, pulse, bruising, bleeding pain level) Ask how takes? Gather supplies Evaluate/administer Sign MAR
ABD Assessment WIP Pee, position, pain Sx off ~ on Look Listen Glove (if app) Feel
RESP Assessment WIP Position Rhythm/rate/pattern Equipment Ascultate bilaterally Tell pt breath deep/slow Hear ABN/NORM O2 Sat
Skin Assessment WIP 2 areas Moisture Edema Temperature Integrity Color
Comfort Management WIP Comfort level Oral care Medication Bed linens Heat/cold (if assigned) Environment Reposition Distraction Backrub Ask mom (toy, feed, diaper, pacifier) Wash cloth Record Response
Exit Down bed/brakes Evaluate need Side rails up I&O Remember call light Evaluate comfort Sanitize
Other AOCs MUSC Mgmt WIP ABN Mobility Pain w/ movement Traction ROM Assess response Supportive/therapeutic devices Heat/cold if assigned (barrier, Record response right temperature) x 20 min, O2 Mgmt WIP Activity tolerance Oxygen administered Nail bed color/cap RF or O2 sat Skin around tubes Position Humidification Equipment (set/maintain) Record response Pain Mgmt Pain level Assess location, characteristics, duration Implement X 3 Need to reassess after 30 min Record response RESP Mgmt WIP Position Rhythm/rate/pattern Equipment Ascultate bilaterally Tell pt breath deep/slow Hear ABN/NORM O2 sat Gloves Emesis Resp. hygiene & Reassess
Pillow (splint) if app Sx <15 secs
Wound Mgmt WIP Wound drainage Observe type, appearance, location Unique cleanser/irrigant:Receptacle
Drainage Specimen Amount Container Color Obtain
WIP
Enteral Continous Intermittent Id Type Position Exp Label Verify feeding Strength Flow Rate NG tube Placement & residual ID Tubing (kinks, etc.) Volume (note) Placement Residual
WIP
Irrigation WIP Type Temperature Amount Placement (pt & receptacle) Tube placement In correct area Rate Record Device
Away Protect skin
Need pack/topical? Dressing-date, time, initials Record response
Remove tube (assigned) Skin around (assigned) Record Patency Gravity
In correct cavity (assigned) Transport
Position
I&0
Patient Teaching Learning readiness Evaluate need Accurate info Reassess understanding Need to document
