Term
Abdominal assessment
Abdomen flat (or soft, firm), symmetrical contour, non-distended with active bowel sounds all four quadrant. Abdomen soft, no tenderness or rigidity in all four quadrants. No complaints of pain or discomfort during assessment. |
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Definition
PPPP TRDS
Privacy, Pee, Pain, Position
Look, Listen, Feel
Tenderness, Rigidity, Distention, Sounds |
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Term
Comfort management
Pt. states she was comfortable. Offered warm water and wash cloth to wash face and hands. Backrub given. Bottom sheet straightened, and repositioned patient to right side. Patient stated that she was more comfortable. |
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Definition
N3R
Needs (for comfort)
3 things (Reposition, Relaxation techniques, Rub back)
Response from patient |
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Term
Drainage and Specimen Collection
1030 - 75 ml of clear yellow urine collected from urinary catheter. No odor noted. No complaints noted.
Nasogastric tube draining via intermittent low wall suction with large amount of bile-colored drainage. |
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Definition
AC ~> DC
Amount
Color
Insert tube
Disposition
Clean |
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Term
Fluid management
Narrative note under "Other Observations"
Thee watery green stools within two hour period; total measure 435 mLs. Anal region reddened and patient complained of soreness. Moisure barrier A&D ointment applied/primary nurse notified and nurse states she will put ointment of pt's area. Pt. offered fluids times one, however patient states "I am not thirsty after my orange juice and coffee" |
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Definition
20 minute checks
I&O
Pinch skin
Urine, Liquid BM's in mL's
Anything eaten or drank
Jello and ice cream are liquids at room temperature |
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Term
Irrigation
Pt positioned at 30 degrees in bed. NG tube irrigate with 30 ml of normal saline solution at 1000 hours. Light green fluid returned via low suction; patient states, "I no longer feel nauseated." |
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Definition
KARRT
Kind, Amount, Rate, Receptacle, Temperature |
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Term
Mobility
Patient found sitting in chair slumped to left side. Hemiplagia of left arm and leg is present. Sling supporting left arm in place. Repositioned in chair, in proper alignment, supported with pillows. States feeling more comfortable since being repositioned. |
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Definition
MAB PTA Response
Mobility level
Assistive devices
Balance abnormalities
Positioning, Transfer, Ambulation activities
Response
Support, offload |
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Term
Musculoskeletal Management
Passive ROM to upper extremities. Pt. demonstrated full abduction and adduction of left and right upper extremities. Joints move freely and has good muscle strength and flexibility bilateral. Tolerated activity well with no complaints of pain or discomfort. No abnormalities noted. Patient maintained in proper alignment. |
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Definition
PAM, BAM, PAT Response
Pain, Abnormalities, Mobility level
Balance, Assistive devices, Mobility Level
Positioning, Ambulation, Transfer activities
Response |
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Term
Neurological Assessment
Patient is alert and oriented to person, place and time. Behavior appropriate to situation. Pupils equal, round, reactive to light and accomodation. Hand grasps are strong and equal bilateral. Plantar and dorsiflexion strong and equal bilateral. No complainst noted. |
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Definition
LOC F PEN
Level of Consciousness
Fontanel
Pupils
Equality of motor response (Grasp, dorsiflex, plantarflex)
Noxious stimuli |
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Term
Pain Management
Patient complained of pain at the incision site. Rated pain at a 6 on a scale of 1-10. Medicated with Vicodin 1 tab at 0930. Bottom sheet straightened and patient repositioned to left side. At 1000 patient rated pain a 1 on a scale of 1-10. Pt resting well.
Patient complained of sharp right hip incision pain, radiating down her right leg, and rated pain level at 4 on a scale of 0-10. Patient repositioned and back rub given. Patient continued to rate pain as 4 after repositioning and backrub. Level of pain reported to assigned staff nurse who medicated the patient with 2 tablets of Tylenol #3 at 0915. Thirty minutes afer taking the Tylenol #3, the patient rated level of pain as 1 on a scale of 1-10. |
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Definition
RP CD RRR
Rate, Point, Characteristics, Duration
Reposition, Relaxation techniques, Rub back
Reassess, Record |
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Term
Oxygen Management
O2 at 2L/min via nasal canula. Patient offers no complaints. Skin around the nares and behind the ears intact and dry. O2 sats at 98%, pulse 80/min with respirations at 16 regular and unlabored at rest. Nail beds pink. Cap refill less than 3 seconds. Pt ambulated to bathroom and back to bed. No shortness of breath with activity. |
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Definition
SHOFARR
Skin, Humidity, O2 sat, Fingernail, Activity, Rate of flow, Response |
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Term
Patient Teaching
Patient eager to learn about medication. After providing information about the use, indications, and side effects of Toprol the patient could restate why medication was prescribed. |
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Definition
MAB QA QA RIR
Motivation, Abilities, Barriers, Question&Answer Them
Question&Answer Me
Readiness, Information provided, Response |
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Term
Peripheral Vascular Assessment
Both feet and hands are warm to touch, nail beds pink. Radial and pedal pulses strong and equal bilateral. Capillary refill less than 3 seconds on feet and hands. Patient able to move feet and toes on command. Patient responds to tactile stimuli on both feet. No complaints noted. |
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Definition
PCC TRM
Pulses (most distal)
Capillary refill
Color
Temperature, Response (can you feel this?), Move bilateral (wiggle fingers and toes) |
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Term
Respiratory Assessment
Respirations shallow at 16/min. Regular, unlabored. No use of accessory muscles noted. Symmetrical movement of chest. Breath sounds clear in the upper and lower lobes. |
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Definition
SPO2 RAM QD
Sounds, Patterns, O2 sat
Rate, Accessory Muscles, Quality, Depth |
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Term
Respiratory Management
Respirations shallow at 18/minute, regular, unlabored. No use of accessory muscles noted. Symmetrical movement of chest. Breath sounds clear in the upper and lower lobes. Assisted to deep breath and cough 2 times. Cough dry, non-productive. Incentive spirometer done time 2 achieved 3000 ml. Respirations remain shallow at 18/min, regulr and unlabored. Symmetrical movemnt of chest. No accessory muscle used. Breath sounds remain clear in upper and lower lobes. No complaints or dizziness noted. |
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Definition
PRAYS SPAR RAM QD
Position, Receptacle, Auscultate, Cough, Splint
Sounds, Patterns, Activities, Response
Rate, Accessory Muscles, Quality, Depth |
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Term
Skin Assessment
Heels and coccyx are warm to touch, no edema. Skin intact with a reddened area to coccyx. Pt repositioned off the coccyx to left side. No moisture noted. |
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Definition
TIME Check x2
Temperature, Integrity, Moisture, Edema, Color |
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Term
Wound Management
Surgical dressing removed. Scant amount of serosanguinous drainage on dressing noted. Wound cleansed with normal saline. Wound edges approximated. Sutures intact. No redness or inflammation noted at the surgical site. No complaints of pain or tenderness during treatment. Dry sterile dressing applied. No complaints noted. |
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Definition
LT, DA wound, CIP Response
Location, Type, Drainage, Appearance, methods implemented to Cleanse, Irrigate, Protect wound.
Hot wee in a can.
Dirty->Clean |
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Term
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Definition
KONS A VGR
Kind of Oral
Name/Strength
Volume of Gastric Residual |
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Term
| Appendicitis during abdominal assessment? |
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Definition
| Request pain meds. Wait for pain meds to take effect. |
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