-wash hands

-id pt, self & ce

First thing -ask comfort/pain

-glove prn

-do 20 min checks

-turgor

-drip rate

Fluid management -site check

-I&O

-record

-i.v. site

-i.v. tubing

-i.v. flow rate & fluid infusing

-g tube site check

20 minute checks
-g tube tubing

-g tube flow rate & fluid infusing

-O2 flow rate

-cannula & tubing

-assess level of mobility

-assistive devices

-position

Mobility -support injured limbs

-transfer/traction if ordered

-balance

-record

Vital signs -drank nothing 15 min before temp

-glove for oral temp

-clean scale after use

-surgery site/iv arm = no b/p

-balance scale before use

-palpate brachial artery for b/p

-measure O2 sat if ordered

 -do not re-inflate b/p for 1 min

-barrier for scale

-temp

-HR/pulse

-b/p

Vital signs: List of 7 -resp

-O2 sat

-pain scale

-weight

-bed low

-side rails up x2

-phone in reach
Exit
-ask comfort level/pain

-wash hands

-record

-assess in 2 locations

-color

-integrity
Skin assessment
-temp

-edema

-moisture

-pee

-position

-pain

-look
Abdominal assessment
-listen

-feel

-measure girth (if ordered)

-record

Neuro assessment -LOC (A&O, person, place, time)

-PERRL

-Fontanel if <1 year

 -motor response- grasps/pushes

-noxious stimuli

-record

-pulses

-movement

-sensation
Peripheral vascular assessment
-temp

-cap refill

-edema

-O2 sat if ordered

-fowlers position/ HOB up

-sounds bilaterally

Respiratory assessment -pattern/rate

-accessory muscle use?

-labored?

-Lobes (document upper and lower)

-position

-receptacle

-assess: rate, rhythm, sound

Respiratory management -perform measure (IS,DB,Cough)

-splint if necessary

-reassess

-record

Musculoskeletal management -joints

-assess

-movement

-strength

-flexibility

-traction if ordered

-heat

-cold

-re assess
 -pain

-chart

-glove

-assess: location, type, appearance of drainage

-irrigation if ordered

Wound management -cleanse wound w/designated solution

-topical med if ordered

-dressing change if ordered

-record

-assess response to activity

-observe nail beds

-position HOB up

-flow rate

O2 management -humidification

-articles of hazard

-skin under tubing

-sats if ordered

-record

-rate pain

-ask about comfort

-observe signs & symptoms

Pain/comfort management -medicate or inform primary nurse

-do 3 measures

-reassess

-response/record

-select med

-measure dose

Medication -pt i.d.

-administer within 30 min

-MAR documentation within 30 min

Intermittent tube feeding -check gtts

-check placement
 -check residual

-determine amount of feeding

-administer within 30 min

-adjust flow rate

-record

-readiness to learn

Patient teaching -what is being taught

-patient understanding

-feeding type

-position

-check placement

Enteral feeding -residual

-burp if <6 months

-at room temperature

-record

-assess: color, amount, consistency

-clean surrounding tissue if ordered

-insert tube if ordered

Drainage collection
-maintain patency/position

-remove tube if ordered

-record

-select volume, ready patient, instill and record

-select solution

-temp

-verify tube placement

Irrigation
-receptacle

-position

-instill slowly

-record

Speciment collection -obtain speciment in proper container

-label appropriately

-observe: color, consistency & odor

-how was the speciment collected?

-where is it going?

-record