Sunday, December 12, 2010

Day 3 at Grady

Up at 5:30 am without any problem, that in itself is scary!! Read up last night on Sickle Cell etiology, treatments, stats, in preparation for my peds patient today. I know I have done it a dozen times before but with stress I tend to forget. When the examiner did not have a coat on I had to ask if we were going across the street to the Children's Hospital. Image my utter relief when she informed me I had a "peds substitute" adult patient. YIPPEE!! I always want to cry when children are hurting or ill. I did it!!! I PASSED THE CPNE!!!!! Words can not express the joy I have. My husband and I shared some tears of joy as we quickly exited (never to return) Atlanta, GA!!!!!! Merry Christmas!

Saturday, December 11, 2010

Day 2 at Grady

I am still here.....A bit shaky but I passed both PCSs. A child tomorrow - I plan on reviewing again tonight after dinner with a dear friend and her hubby. I will be back.......Sat Nam

Friday, December 10, 2010

Day One at Grady

Shaking like a leaf!! I almost could not hit the stopper in the vial to do the IM. I took some deep breaths mentally said some mantras from my Kundalini teacher and then I could hear my dad's voice telling me to just take a few deep breaths and go slow - don't hurry use all of your time. Then I thought of my turtle anklet. Slow and steady like a turtle, don't lose my head like one of the turtles. Mark echoing my dad was in my head too. God Bless my honey he sat at Grady and waited for 3 hours for me to come down. Thinking of all of the tips and recommendations of those close to me I believe pulled me through. Daily lunchtime practices with Patty made my wound (the first station) a success in record time! Sheri and her confidence in me has given me the "guts" to try one last time, truely the last time. PASS PASS PASS and PASS. Now on to bed and get geared for day 2 - two adult patients. Keep the positive energy flowing! Sat Nam

Tuesday, December 7, 2010

Patient Teaching

Patient teaching is always co assigned with any other  area. Not wise to use as a care plan

determines the patient's readiness to learn
assess the patient's motivation and ability to learn or
identifying barriers to learn
ask questions to identify the patient's specific learning need
provides accurate information that is appropriate for and consistent with the identified learning need of the patient
ask questions to determine the patient's understanding of the information
record
assessment of learning readiness
information provided
patient response to information

calculations for iv rates and medicatons pg 296

 calculating gtt/m
ampicillin 500 mg in 50 ml /ns run over 20 minutes drop factor is 15 ml/m

flow rate (gtts/min)
volume to be administered (ml) x drop factor of the tubing (drop/ml)
Lengh of time to be administered (minutes)

50 x 15 = 750 = 75 =    37.5  ggt/min - round up or down to whole number
20             20      2


erythromycin 50 mg in 100 ml NS
run over 30 min
gtt factor 15

100 x 15 =  1500 = 150= 50gtt/min
30                 30        3   


to calculate ml/hr

divide 60 minutes by the time to infuse the med, multiply the answer by the volume

60/20 = 3
3x50 = 150 cc/hr

16a
60/30=2
2x100=200ml/hr
16b
60/90=066
.66 x100 = 66ml/hr

Medications 17th edition CPNE study guide page 285

Medications must be administered at least once during the CPNE

Select the prescribed medication using the hospital MAR
  • know the side effects, actions and uses of any med you are to administer,
  • follow guidelines like apical pulse rate of BP
Measures the dosage
ID the patient immediately before administering the medication by comparing the MAR to the Bracelet on the patient with 2 identifiers - DOB, Name, MRN
Use the correct size needle
Use the correct dose
administer to the patient within 30 minutes of scheduled time

5 rights of medication administration
  • right med
  • right patient
  • right dose
  • right time
  • right route
IV MEDICATIONS
records the correct flow rate in drops per minute for gravity flow or mls per hour for infusion control devices or the PCS Recording Form before administering the medication
assiss the insetion site for dislocation, infiltration or other complications by :
  • feeling the surrounding skin for changes in temperature
  • palpating the surrounding tissue for edema
clears air from tubing

when an intermittent venous access device is used:
  • aspirates for blood return unless contraindicated
  • flushes with the designated solution prior to medication administration
  • flushes with the designated solution after medication administration
  • records the fluch solution used on the pcs response form
refulates the flow to deliver the prescribed amount in the designated period of time within 5 gtts/min for gravity flow or the correct ICD setting

records the medications administered on the hospital MAR within 30 minutes after administration

Irrigation page 281 17th CPNE Study guide

Irrigations my be intermittent or continuous. Sterile technique is used to avoid introducing microorganism into a wound or body cavity such as the bladder.

determine the appropriate temperature of the solution
positions the patient
verifies the correct placement of the tube - ng instill 10-20 cc air if child 5 cc air and listen then aspirate gastric contents
instills the solution into the designated area
controls the flow rate
positions the receptacle
records the kind of irrigation solution  used and the amount of irrigation solution used, the patient's response or tolerance in the student pcs response form. check if irrigation solution is included in the i & o totals , ask what the hospital's policy is

Sunday, December 5, 2010

Care Plan Question

My question:


If i write a "risk for" care plan, can I use it as my priority and evaluate it if it does not become an actual problem? I think I can but I thought it was not allowed.

I am reading the 17th Edition Study Guide page 280 answer for:
" #6 Write a care plan for a patient receiving enteral feeding via a peg tube following oral surgery for removal of a cancerous lesion of the mouth. What are the possible related factors?
Label: Risk for imbalanced nutrition: less than body requirements related to impaired swallowing
Outcome: Patient will be free of gastric distress during tube feedings
Interventions:
1. Position patient to a 45 degree angle for feeling
2. Administer enteral feeding as prescribed"

My thought on the evaluation all the components are here -
the nursing dx
with the RT aspect
no s/s since it is not an actual problem
Outcome is measurable - no gastric distress during the feeding
importance - According to maslow, nutrition is a basic human need, required for cell regeneration. Without adequate nutrition cell growth and repair can not occur. If an individual experiences gastric distress they may not tolerate adequate nutrition thus preventing tissue repair, strength, and increasing the susceptibility of infection, inadequate circulation, and tissue breakdown.

evaluation of interventions -
effective as the patient was positioned at 45 degrees
the feeding was administered as prescribed

the patient denied any gastric distress.

Enteral Feeding - 17 th Edition CPNE Study Guide - Excelsior pg 270-271

Feeding by bottle, tube or other device to infants, children or adults.

  • For all feedings:
    • select the correct formula
    • position the patient
    • deliver the feeding
  • When assistance is designated:
    • choose the appropriate device
    • burp an infant under six months old periodically, as needed
  • Administer the feeding at room temperature unless otherwise directed.
  • intermittent Tube feeding:
    • determine the amount of feeding
    • calculate the gtts/min
    • verify the location of a NG by:
      • instilling 10-20 cc (5 mm for child <2) of air into the tube while listening to the abdomen
      • aspirate amount of gastric contents
      • record amount of gastric contents
      • reinstill gastric contents
    • initiate feeding within 30 minutes of scheduled time
    • regulate the rate to be within the specified time by
      • adjusting the flow rate to within 5 gtts/min
      • or setting the icd to the prescribed flow rate.
  • continuous tube feeding:
    • within the first 20 minutes
      • verify type of feeding
      • verify rate either by gtt/min or icd setting
        • regulate the flow if needed within 5 gtts/min
        • or adjusting the rate on an ICD to the ordered rate.
      • document same on the PCS recording form
    • verify the position at least once during the PCS by
      • instilling 10-20 cc (5cc for child <2) air and listening to abd and
      • aspirating gastric contents
    • when measurement of gastric residual is designated:
      • measure gastric residual
      • reinstill gastric residual unless contraindicated
      • determines the amount of feeding to be administered
  • Records the kind of oral feeding administered
  • Records the name and strength of the feeding product for a  patient receiving a tube feeding
  • Records the amount of feeding
  • Records the volume of gastric residual measured

Interesting or Not

Vickie's Views

Tuesday, November 30, 2010

Other Selected Areas of Care page 265 CPNE 17th Edition Study Guide - Drainage and Specimen Collection

Removal of body secretions from a a body cavity or wound, includes care and protection of surrounding skin.
ID Patient
remember to wear gloves
explain procedure to patient

  1. when drainage collection is assigned: (foley, hemovac, JP, NG)
    1. assesses the amount and color of drainage
    2. cleans surrounding skin or tissue - when assigned
    3. insert the tube into the apropriate body cavity
    4. when drainage is by tube
      1. maintain or attach tube to container
      2. maintain patency of tube
      3. maintain drainage by suction or gravity
      4. removes tube when assigned
  2. when specimen collection is assigned: (urine, feces, sputum)
    1. obtain designated specimen
    2. place the specimen in the designated container or on the designated surface
    3. ensures that the spicimen is labeled
    4. places specimen in designated area for transport
  3. record data related to drainage amount and color
  4. record data related to specimen collection
  5. document or report disposition of speciment
Documentation includes recording on the PCS recording form for the disposition of specimen. Additional data is to be written in "Other Observations" in the narrative note section.

Monday, November 29, 2010

Wound Management - Critical Element Selected Area of Care 17th Edition CPNE Study Guide

"Wound Management is the assessment of a wound and the implementation of measures to clean, irrigate, and protect the wound and surrounding skin." page 257

  1. Assess the wound location, type,  (incision, contusion, abrasion, laceration, puncture, penetrating wound, pressure ulcer) appearance of the wound bed (granulation, necrotic), and presence or absence of drainage (purulent, serosangenous, bloody). Signs of infection - redness, odor, pain, warmth.
  2. When irrigation is designated:
    1. Selects the designated solution
    2. Determines the appropriate temperature of the solution
    3. Uses an appropriate irrigation delivery system
    4. Positions a receptacle for return flow
    5. Irrigates without contaminating the wound
    6. Protects the surrounding skin from contact with the drainage
  3. Cleanses the wound with the designated solution
  4. When wound packing is assigned:
    1. prepares gauze for application to wound bed
    2. packs wound by applying a sterile moist dressing to wound bed surface
  5. Applies the designated topical preparation
  6. When wound protection is required:
    1. removes the dressing without contaminating the wound
    2. removes the dressing without injuring the surrounding skin
    3. disposes of the soiled dressing in the designated container
    4. applies the dressing without contaminating the wound
    5. secures the dressing
    6. labels the dressing with date, time, and their initials
  7. Records data related to wound:
    1. location
    2. type
    3. appearance
    4. presence or absence of drainage

Sunday, November 28, 2010

Care Plans found in the 17th edition Excelsior CPNE study guide

When writing a care plan use Kardex and what you are assigned.
  • Respiratory Management:
    • Ineffective airway clearance r/t retained secretions aeb ineffective cough, inability to move airway secretions, abnormal breath sound, abnormal respiratory rhythm, rate and depth
      • goal: patient will perform respiration hygiene activities
        • interventions - depend on assigned -
        • Direct patient to perform IS x 10
        • Instruct patient to perform deep breathing and coughing
        • suction secretions
        • assess respiratory status
 Oxygen Management:
  • Impaired gas exchange r/t ventilation - perfusion imbalance aeb oxygen sturation of <93% on room air
    • goal (Outcome) patient will have oxygen saturation equal to or < 93% during PCS
      • monitor oxygen saturation
      • position patient to facilitate respiration
Muscular Skeletal Management:

Respiratory Management Excelsior CPNE 17th Edition Study Guide p 244

***wear gloves- be prepared of secretions***

This is assessing the lungs and encouraging/instructing/assisting respiratory hygiene activities and reassessing.
Respiratory Hygiene activities include:
  • incentive spirometry
  • chest percussion
  • deep breathing and coughing
  • suctioning
  1. Position the patient - depending on patient's tolerance - Head of bed high Fowler's or sitting on side of bed, if Chest Percussion have patient lying on side to facilitate drainage
  2. Provide a receptacle for secretions if any are produced (wear gloves)
  3. Assess lungs immediately prior to initiating any respiratory hygiene activities by placing the stethoscope directly on the skin
    1. instruct the patient to breathe in and out slowly and deeply
      1. observe for regularity, use of ancillary muscles, quality and depth
    2. auscultating breath sounds over upper and lover loves by moving the stethoscope from side to side
    3. watch breathing patterns
  4. Directs the patient to perform breathing exercise
    1. Deep Breathing
      1. instructs the patient specifically to breathe in and out as deeply as possible
      2. Repeats deep breathing exercises as ordered or as indicated by the patient's condition
    2. Coughing
      1. instructs the patient specifically to breathe in and out deeply
      2. instructs the patient specifically to cough forcefully on the 3rd or 4th expiration
      3. provides for splinting while the patient is coughing if necessary
    3. Mechanical Devices such as incentive spirometry:
      1. instructs the patient to use the device
        1. video links:
          1. instructions for using Incentive Spirometry
        2. repeats exercise as ordered or as indicated by the patient's condition
    4. Chest Percussion
      1. claps the designated area of the chest wall vigorously with cupped hands unless contraindicate
      2. vibrates the designated area of the chest wall vigorously unless contraindicated
        1. Video link - Nurse's Video of How to Perform Chest Percussion
    5. Suctioning:
      1. when assigned suctioning by catheter (have patient take a few deep breathes if possible)
        1. verifies patency of catheter
        2. set the pressure on the suction machine as designate
        3. insert the catheter before suctioning
        4. suction for no more that 15 seconds at a time
        5. repeat as necessary - allow patient to re-oxygenate prior to re-suctioning
      2. when assigned suctioning by bulb syringe
        1. deflate bulb prior to suctioning
        2. insert bulb into the patient's mouth or nares before suctioning
        3. aspirate secretions
        4. repeat as necessary
    6. Reassesses respiratory status immediately after respiratory hygiene activities
    7. Record
      1. bilateral breath sounds heard after treatment in comparison with those heard initially, related to each of the above assessment findings
      2. abnormal breathing patterns
      3. respiratory hygiene activities implemented
      4. patient response to hygiene activities implemented

Saturday, November 27, 2010

Pain Management p 232 17th Edition CPNE Excelsior Study Guide

ask patient to rank pain:
  • Adults on scale of 0-10,  or a visual analog scale
  • child of 3 or older use the faces 0-5 or visual analog
  • 2 months to 3 years use the FLACC
  • observing behavior indicative of pain
assess patient's pain location by asking the patient to point to the location of the pain
  • if the patient is unable to verbalize or communicate location observe
    • pulling on ear
    • limping
    • rubbing  an area
assess the quality of the pain by asking the patient the characteristics of the pain
  • sharp
  • dull
  • stabbing
  • aching
  • throbbing
assess the duration of pain by asking the patient:
  •  how long does the pain last
  •  how often does it occur
  • how long have you experienced this pain
provide three of the following pain relief measures
  1. repositions the patient or assists the patient to a different position
  2. gives the patient a back
  3. uses relaxation and/or distraction techniques
    1. guided imagery
    2. watching TV
    3. drawing a picture or coloring
    4. engage in conversation about a happy memory or hobby
    5. pacifier
    6. cuddling
    7. play
    8. singing
  4. applies heat or cold when assigned
  5. administer pain med when assigned, or
  6. if not assigned request the primary nurse to administer pain med
reassess the patient's pain by:
  • asking the adult patient to rate the pain on a scale of 0-10 or visual analog scale
  • asking the child of 3 or older to rate the pain on a 0-5 Faces scale or visual analog scale
  • using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age
  • observing behavior indicative of pain in an infant or noncommunicating- adult or child
    • moaning,
    • grimacing
    • clutching
    • restlessness
Records:
  • level of pain
  • location of pain
  • intensity of pain
  • duration of pain
  • characteristics of pain
  • predisposing factors
  • aggravating factors
  • measures to relieve pain
  • patients response to measures to relieve pain

Friday, November 26, 2010

Oxygen Management pg 224 Excelsior 17th Edition CPNE Study Guide notes for self

"AIR  for all management of care Assess - Implement - Reassess/Reevaluate" *page 206

make sure there are no items at the bedside that could spark, remove if present.
verify oxygen delivery - lpm, device, humidity
skin inspection - nares, ears
tolerance to activity - watch for shortness of breath, change in vitals,
oxygen saturation - either by device if assigned or by nail beds, color, cap refill, or clubbing - report if outside of perimeters if <93%

record everything you do and how the patient responds
response to activity
oxygenation status
condition of skin surfaces in contact with oxygen delivery system
oxygenation management measures implemented

Sunday, November 21, 2010

Musculoskeletal Management - Excelsior CPNE Study Guide pg 214 - 223

Assess the affected area of the designated extremity for:
  • abnormalities - atrophy or contractions
  • mobility - active or passive - bed, chair, ambulating
  • pain with movement
Direct the patient to move the joints of the designated extremity through active range of motion (AROM) by one of the following:
  • abduction and adduction
  • flexion and extention
Perform passive range of motion (PROM):
  • support the weight of the extremity at the joint
  • moving the joints of the designated extremity as above, smoothly, rhythmically
Apply supportive or therapeutic devices : such as CPM, Brace, TEDS, Immobilizers, Sequential Hose (SCD)

Apply heat or cold when assigned :
  • protect the skin surface by use of a barrier
  • apply to the appropriate area
  • proper temperature maintain for at least 20 minutes unless otherwise ordered
Maintains traction:
  • verify the correct weight
  • make sure ropes are unobstructed
  • make sure the weights are free
  • make sure good alignment
  • counter traction
Record all observations, actions and responses.

Comfort Management - pg 207 Excelsior CPNE Study Guide 17th Edition

Assess comfort needs by asking the patient if they are comfortable or need anything or observing behavior.
Provide 3 comfort measures: (TLC)
  1. reposition
  2. wash face and hands
  3. backrub
  4. distraction - if child playing, singing, giving favorite toy, pacifier
  5. adjust pillow or linens
  6. mouthcare (don't forget the gloves)
  7. medications (if assigned)
  8. heat or cold (if assigned)
Record what the patient said and what you did and the patient's response.

Wednesday, November 17, 2010

Skin Assessment - Excelsior's 17th Edition CPNE Study Guide pg 203 - 205

Assess at least 2 bilateral vulnerable skin surfaces. Examples are right and left heels and right and left hips, or bilateral ears and occipital region, coccyx and bilateral elbows. The idea is that if the area has a corresponding opposite - right and left it only counts as one site.

When assessing check the color - is the area pink, red, blue, black?; temperature - is the area warm, hot, cool. or hot?;  integrity - is the skin intact, are there abrasions, rashes, lesions?, moisture - is the area moist, dry, diaphoretic and sweaty or flaky? is the area prone to breakdown from incontinence or sheet sheering when repositioning?

Document all finding include any abnormalities and paint a picture. Be specific with size in cm or mm, color, edema, weeping, and what you did to address the problem, repositioned to relieve pressure, elevated on pillow, pericare to clean incontinence. Document the position the patient was in originally and the position you left the patient in. Report to primary nurse and deviation for baseline.

Tuesday, November 16, 2010

Respiratoy Assessment 17th edition study guide pgs 200 - 202

Listen over the intercostal space not on the bones, move the stethoscope from side to side from top to bottom directly on the skin.

  • Have the patient in an upright position if possible, the patient may be positioned on the side, for those unable to sit up or lie on their side anterior assessment is acceptable.
  • Instruct the patient to breath in and out slowly and deeply while listening to each side only need to listen to upper and lower
  • Compare right to left
  • Observe breathing pattern - watch torso for regularity, use of ancillary muscles, quality and depth
  • Oxygen saturation when assigned

Document normal or abnormal - not wheezes, rales, ronchi, shallow or deep, regular or irregular, address upper and lower right and left lobes, and how patient tolerated. If there is any oxygen and if sat is ordered record the percentage.

Great learning tool for lung assessments

Monday, November 15, 2010

Fluid Management

Within the first 20 minutes of implementation make sure to check hydration, IV or Enteral fluids and record.
  • skin turgor
    • gentle pinch of subclavicular area - for tenting
    • inspection of mucous membrane - for moisture  (use gloves)
      • palpate the anterior fontanel of a child less than 1 year old - for depression
  • verify type of fluid in IV or Enteral (if continuous feeding)
  • verify rate of infusion of IV or Enteral
    • if continuous flow check rate on device - must be exact number prescribed on kardex
    • if gravity flow count gtt/min - must be within 5 gtts of calculated number of gtts/min
  • verify patency of IV or Enteral feeding tube (use gloves)
    • if IV check placement by palpating for temperature and edema
    • if Enteral check placement by aspirating gastric contents and instilling 20 - 30 cc of air prior to initiating feeding.
Throughout PCS:
  • record intake and output if assigned
  • if change or new solution required
    • access insertion site for temperature and/or edema
      • if intermittent access device check patency by checking temperature and edema and aspirate to blood return prior to flushing
      • flush with prescribed solution before and after administering medication
    • clear all air from tubing
    • regulate rate as above
  • administers the designated amount of fluid per our within the following ranges:
    • +- 25 ml/hr
    • +-10 ml if under 2

When intake is assigned:
  • measure the amount of fluid ingested or infused
  • record fluid intake within +- 10  %  of the actual intake
When output is assigned:
  • collects output
  • measures output during entire PCS
  • records amount of output within +- 10% of actual output for the PCS on the recording form
    • output from foley or other drainage device is not measured during the PCS unless otherwise designated
If assigned to discontinue an IV assess site, remove cannula, apply pressure to site and apply protective covering. record all.

Record hydration status and condition of insertion site within first 20 minutes on the recording form.

If ICD alarm sounds - verify the tubing is not kinked or the site is not infiltrated..."ask the CE or staff nurse to assist with turning off the alarm" page 149 17th edition of the CPNE Stufy Guide.

Saturday, November 13, 2010

quote of today

Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.


~ St. Augustine

This prayer was on the cup I chose to drink my coffee from and when I went on-line it was there on my i-google. When I checked my e-mail, I had a message from a friend that rarely sends me e-mail (I think this was the first) and although it was not the serenity prayer, it held a very similar message. The courage to keep trying to reach your goal, serenity with failures, and wisdom to believe in your ability, just to try a different strategy. 
 
"'To get something you never had, you have to do something you never did.' When God takes something from your grasp, He's not punishing you, but merely opening your hands to receive something better. Concentrate on this sentence... 'The will of God will never take you where the Grace of God will not protect you."

I believe everything happens for a reason, no coincidences. I was still not wanting to take a final try at the CPNE for all of my efforts hours of studies and practicing had not resulted in a successful exam twice. I am not religious but I do believe in God, okay this gets even more weird - while looking for the origin of the quote I found the following on a website selling a tool the  Freedom Wand for disabled individuals to be independent.
So don’t get tired of doing what is good. Don’t get discouraged and give up, for we will reap a harvest of blessing at the appropriate time. Galatians 6:9 (NLT)
*** *** *** ***

There are many things that work to keep us from completing our life-missions. Over the years, I’ve debated whether the worst enemy is procrastination or discouragement. If Satan can’t get us to put off our life missions, then he’ll try to get us to quit altogether.

The apostle Paul teaches that we need to resist discouragement: “So don’t get tired of doing what is good. Don’t get discouraged and give up …” (Galatians 6:9 NLT).

Do you ever get tired of doing what’s right? I think we all do. Sometimes it seems easier to do the wrong thing than the right thing.

When we’re discouraged, we become ineffective. When we’re discouraged, we work against our own faith.

When I’m discouraged, I’m saying, “It can’t be done.” That’s the exact opposite of saying, “I know God can do it because he said ….”

Ask yourself these questions:

· How do I handle failure?

· When things don’t go my way, do I get grumpy?

· When things don’t go my way, do I get frustrated?

· When things don’t go my way, do I start complaining?

· Do I finish what I start?

· How would I rate on persistence?

If you’re discouraged, don’t give up without a fight. Nothing worthwhile ever happens without endurance and energy.

When an artist starts to create a sculpture, he has to keep chipping away. He doesn’t hit the chisel with the hammer once, and suddenly all the excess stone falls away revealing a beautiful masterpiece. He keeps hitting it and hitting it, chipping away at the stone.
And that’s true of life, too: Nothing really worthwhile ever comes easy in life. You keep hitting it and going after it, and little-by-little your life becomes a masterpiece of God’s grace.
The fact is, great people are really just ordinary people with an extraordinary amount of determination. Great people don’t know how to quit.

  I believe it is the subtle things that are messages to heed only I am not so sure this was all that subtle????

Friday, November 12, 2010

PVA 17th edition study guide pg189-199

Assessment of the temperature, perfusion, pulse, sensation, and movement

compare bilateral extremeties always start at the most distal location, compare at same anatomical site
  • palpate the most distal pulses ; assess strength and equality or absence of (pulse)
  • check color or capillary refill - should be less than 3 seconds (perfusion)
  • check tempurature - warm, cool or hot, cold - dry or moist (perfusion)
  • sensation - light tactile  stimuli to most distal (sensation)
  • movement, start with most distal  - wiggle toes or fingers (movement)
Record all of the findings!
think of your assessment - provided privacy, tempature when you touched skin, location of palpable pulses, color, edema, lesions, response to stimuli, ability to move - what they moved.

Thursday, November 11, 2010

Neuro Assessment 17th study guide pgs 181-188

Neurological Exam this link goes through a thorough neuro exam.  For the CPNE be sure to include:
  • level of consciousness - orientation to time, place, and person
    • or recognition of familiar people or objects if under 1
    •  if noncommunicating adult or child between 1 and 3 - presenting visual, auditory, and tactile stimuli
  • pupils - size, equality, reaction to light - use flashlight
  • motor response - to touch, strength, equality - use both hands for grasp and dorsiflex or plantar flex both feet
    • if child under 3 or noncommunicating adult or child observe symmetry and movement
*if unresponsive to verbal stimuli check response to noxious stimuli (pressure to the nail bed)
**if a child under the age of one, check the anterior fontanel for bulging by gently palpating while child is in an upright position. photo of a baby's anterior fontanel

Record:
  1. LOC
  2. Assessment of fontanel (if applicable)
  3. PEARL
  4. equality of motor response
  5. response of noxious stimuli (if applicable)

Abdominal Assessment: 17th edition study guide pgs175 - 180

What are the established guidelines we are to comply with?
  •  look - for distention or asymmetry, rashes, scars, wounds, dressings, any abnormalities
  • listen - check for bowel sound in all 4 quadrants, make sure to listen for one full minute before declaring no bowel sounds and in all quadrants.
  • and feel - light palpation checking for rigidity, tenderness, masses
Before beginning make sure the patient does not need any pain medication or need to void. prior to placing in the correct position make sure you provide privacy. This ensures you do not place the patient in emotional or physical jeopardy.

Alright now the patient has privacy, pain controlled, bladder emptied and in position. The best position is supine with the knees slightly bent and the head as low as tolerated, no more than 30 degrees.

Record all findings, report any deviation from baseline to primary care nurse.

Monday, November 8, 2010

Mobility 17th edition study guide pgs 129 -137

 17th Edition Critical Elements for Mobility:
Assess for:
  • level of mobility - is the patient independent or need assistance - how much
  • use of assistive devices - does the patient use a cane or a walker or a prosthetic device
  • presence of balance abnormalities - is the gait steady is the patient able to coordinate movements purposefully to pposition self
moves or positions the patient by:
  • supporting the weak or injured parts of the body
  • supporting the patient's head, shoulders, and pelvis
  • turning, lifting, or moving the patient toa different position
  • using body parts or external devices to keep the patient in the desired position
  • using positioning and / or devices to reduce pressure on vulnerable skin surfaces - wedges
  • using measures to prevent shearing of skin - draw sheet
Assist with transfer or ambulation by:
  • stabilizing equipement
  • using measures to maintain the patient's balance

Records:

  1. level of mobility
  2. use of assistive devices
  3. presence of balance abnormalities
  4. positioning, transfer or ambulation activities during the PCS
  5. patient's response

Tuesday, November 2, 2010

Critical Thinking Exercise - Care Plans 17th edition page 84

  1. Which of the following addresses an actual or potential health problem that can be prevented or resolved by nursing interventions only?
        1. Nursing Diagnosis
        2. Nursing Assessment
        3. Medical Diagnosis
  2. Determine the nursing diagnosis statements that are written correctly and identify the errors in the incorrect diagnoses.
        1. Inpaired Skin Integrity related to Mobility deficit as evidenced by ulcer on right heel. - Impaired Skin Integrity r/t physical immobilization aeb distruction of skin layers. page 653 correct
        2. Nausea and vomiting related to medication side effects - Nausea r/t pharmaceuticals aeb report of nausea incorrect
        3. Impaired gas exchange  related to altered oxygen transport as evidenced by oxygen saturation of 90% on room air - Impaired gas exchange r/t ventilation - perfusion imbalance aeb abnormal o2 sat of 90% on room air correct
        4. Needs assistance walking to bathroom: related to immobility - Impaired physical mobility r/t muscular skeletal impaiment aeb gait changes incorrect 
  3. Develop an actual diagnosis and a risk diagnosis for the following patient.  - A 60 year old male patient , 2 days status post (s/p) right total hip replacement. Your assignment includes:
    1. a regular diet
    2. transfer to chair for lunch, right toe touch only during ambulation, abductor pillow between legs while in bed
    3. codeine po for pain
    4. dressing change to right hip
      1. Actual Diagnosis - Impaired physical mobility r/t muscular skeletal impairment aeb limited range of motion
      2. Risk Diagnosis - Falls, risk for r/t impaired physical mobility

Saturday, September 4, 2010

things not to do -

  • Don't forget to compare the wrist band to the Kardex with in the first 20 minutes.
  • Don't forget to compare the wrist braclet to the MAR before handing the patient the med cup.
  • DON'T forget to fill out the evaluation page of the careplan.
  • don't let the examination intimidate you and make you lose you faith in yourself.

Wednesday, August 18, 2010

Slide show of destressing in Georgia and North Carolina

The best way to destress is to trust in yourself and let it go. Do something totally unrelated and enjoy, give your brain a break. Then go back full force till the event. Here is a slide show of my De-Stress to Test.

destress to test

Tuesday, July 20, 2010

IV Therapy

As LPNs we are limited to just what we can do with IVs. Here is a link to a site that will help with troubleshooting and drip calculation for LPNs getting ready for the CPNE.

IV Therapy

Sunday, July 4, 2010

Sheri Taylor's Workshop

This is an awesome resource! Scroll down and read, wonderful blog with good tips and information - thanks Sherri!

Tuesday, June 29, 2010

Care Plan with Comments by Dr. A.

Morning Victoria,
See comments.
Dr. A
Sharon A. Aronovitch, PhD, RN
Faculty, ADN Program

Previous Message:
Mrs. Crow is a 70 year-old white female with a history of early Alzheimer's Disease. She is widowed and lives alone. She fell at home and fractured her right hip. She was brought to the E.D. two days after the fall with severe pain. An open reduction internal fixation was done two days ago. She experienced urinary retention 24 hours post-op and a 16 Fr Foley catheter was inserted. The urine was cloudy with several mucus plugs noted in the tubing. She is oriented to person and place, but not time. She has an order for Tylenol with codeine every 4 hours prn for pain. Her most recent dose was 2 hours ago.
Areas of Care:
* Fluid Management - I&O

* Vital Signs - BP, RR, HR (radial), T (oral)

* Safety/Other - SR X2 up at all times, TEDS continuously

* Mobility - Out of bed with therapy only; reposition X1

* Irrigation - Irrigate F/C with 50ml NS to a closed system

* Musculoskeletal Management - Abductor pillow at all times; AROM of bilateral upper extremities

* Comfort Management - 3 comfort measures

CP #1 – Impaired Physical Mobility r/t loss of integrity of bone structures aeb limited range of motion
Goal:
Pt will be {This is your assignment, which is a nursing intervention. A nursing intervention cannot be used as the patien toutcome. Think beyond your assignment and PCS time frame for the patient outcome.} repositioned once during PCS
Interventions:
1. Reposition the patient with abductor pillow maintained
2. Encourage patient to perform AROM exercises with upper extremities

CP#2 - Risk for Injury r/t confusion
Goal:
Patient will remain free of injury during PCS
Interventions
1. Maintain SR x2 at all times
2. Re-orient to time place and events

CP #1 Priority – rationale – {My first suggestion is to not write the rationale in 1 long sentence.} physical mobility is a basic physiology need according to Maslow,{stop here} if the patient is not able to mover herself, tissue perfusion will be impaired, muscular skeletal contractures or atrophy may develop, strength will diminish and patient will loss ability to perform ADLS. {OK, so why is all of this a problem for the patient?}

Documentation
Fluid management/irrigation:
Patient’s skin turgor on chest good, oral mucosa moist and pink, accepted 120 cc water during pcs. #6 French Foley catheter patent ; Irrigation: irrigated with 50 cc NS with cloudy dark amber urine returned to closed drainage system, no mucous plugs noted. Aseptic technique maintained. Patient tolerated without any complaints of discomfort.
Safety: {This would be documented in Other Observations.}
Bilateral side rails up, bed in low position, TEDS maintained Oriented patient to surroundings and instructed to use call light for assistance. Patient verbalized understanding.
Mobility/Musculoskeletal Management;

Physical Therapy not present during PCS. Repositioned on left side with pillows propping patient off buttock, Abduction pillow maintained. Good alignment maintained. Patient tolerated procedure with no distress noted or verbalized. {Missing narrative note for musculoskeletal management.} {All of this is for PVA: Wiggles toes, good capillary refill bilateral toes, sensation present to light touch. Pedal pulses strong bilaterally. Skin of bilateral lower extremities warm} and dry.
Comfort Management:
{What was initial assessment of comfort or patient needs?} Repositioned with patient verbalization of comfort, back rub given, and face washed. Patient verbalized appreciation and stated feels better and rated pain as 2 on a scale of 0-10.

Care Plan with comments by Dr. A.

Hi Victoria, Good work, see the few comments.

Dr. A

Sharon A. Aronovitch, PhD, RN
Faculty, ADN Program

Previous Message:
Please review the careplan and documentation. Thanks! Vickie

27 y/o male who, over the last year, has steadily gained weight, especially around his waist. After being diagnosed with Cushing’s Disease he attempted weight loss with a variety of OTC “remedies”. As a result he has liver failure and has been admitted for a liver biopsy. Has acute ascites, which is causing some dyspnea. Oxygen 2lpm NC. His extremities are atrophied. Has some abdominal pain, last rated 4/10 and constant. Fentanyl ordered PRN for pain. VS: AP, BP, R, oral temp, SpO2 IV: D5NS 65 ml/hr I&O: Restrict oral fluid to 300 ml during PCS Mobility: OOB to chair with assist, ambulate down hall x1 as tolerated with assist AOCs: Abdominal assessment – girth measured at level of umbilicus Respiratory management – IS x10 qhour PVA – lower extremities Comfort management

CP #1
Ineffective Breathing Pattern r/t decreased lung expansion AEB dyspnea
Goal:
Patient will report ability to breath comfortably during PCS
Interventions:
1. Administer oxygen as ordered at 2lpm NC
2. Encourage patient perform IS x10 per hour
CP #2
Excess Fluid Volume r/t compromised regulatory mechanism AEB ascites
Goal:
Patient will explain measures that are to be followed to treat excess fluid volume, especially fluid restrictions.
Interventions:
1. Restrict PO fluid intake to 300 ml uring PCS
2. Measure girth at umbilicus

CP # 1 – Rationale: According to Maslow adequate ventilation is a basic physiological need. With out effective breathing patterns oxygenation will be impaired and further complications can occur such as pneumonia .

Documentation:
Fluid management:
IV site right forearm without inflammation or edema, D5/NS infusing via pump at 65 ml/hour. Oral mucosa moist and pink, reviewed fluid restriction and I&O procedure with patient. Understanding verbalized.
Abdominal Assessment: {Abdominal girth is no longer a critical element.}
Curtain pulled for privacy, patent denied need to void, Head of bed at 30 degrees due to dyspnea and knees flexed 45 degrees. Abdominal girth 58 inches at umbilicus. Abdomen rounded and firm all quadrants. Bowel sounds active all 4 quadrants, Patient rates pain in ribs and general abdominal area at a constant 4 on a scale of 0-10. Not increased with palpation.
PVA:
{This is an assessment for musculoskeletal management: Bilateral lower extremities noticeably atrophied. } Pedal pulses palpated bilaterally, skin warm to touch, capillary refill <3 seconds on bilateral toes, wiggles toes bilaterally, acknowledges light touch on dorsal and planter aspects of bilateral feet.
Comfort:
Reported patient’s pain to RN and medicated with fentanyl by RN. Assisted patient to left side and provided back rub. Mouth care and facial wash accepted. Patient stated, “I feel better now”
Respiratory Management:
Oxygen maintained at 2 lpn via NC. Head of bed in semi-fowler’s position skin on nares and ears intact with no redness noted. Assisted patient to fowler’s position, Lung sounds decreased bilaterally posterior upper and lower lobes. Performed IS x 10 repetitions. Reassessed lungs with {The correct term is clear.} normal breath sound upper bilateral lobes and right lower lobe, left lobe remains abnormal. No sputum expectorated.
Mobility:
Assisted patient to side of bed and dangled x1 minute. Assisted with ambulation in hall 50 feet, with nasal o2 tank. Returned to room and sat in chair. Tolerated activity with slight dyspnea. Patient stated, “Boy that really takes a lot of effort”

Wednesday, June 23, 2010

Care Plan with corrections - Thanks Sherri!!

Below is a care plan I sent to Sherri Taylor - CPNEworkshop.com With corrections noted in red, bold font and yellow highlight. I went to the workshop in Atlanta in January - the wisest thing I could have done. The support doesn't end till I pass. Thanks Sherri!!
The scenario is courtesy of Chuck.


Mrs. Crow is a 70 year-old white female with a history of early Alzheimer's Disease. She is widowed and lives alone. She fell at home and fractured her right hip. She was brought to the E.D. two days after the fall with severe pain. An open reduction internal fixation was done two days ago. She experienced urinary retention 24 hours post-op and a 16 Fr Foley catheter was inserted. The urine was cloudy with several mucus plugs noted in the tubing. She is oriented to person and place, but not time. She has an order for Tylenol with codeine every 4 hours prn for pain. Her most recent dose was 2 hours ago.


Areas of Care:
* Fluid Management - I&O
* Vital Signs - BP, RR, HR (radial), T (oral)
* Safety/Other - SR X2 up at all times, TEDS continuously
* Mobility - Out of bed with therapy only; reposition X1
* Irrigation - Irrigate F/C with 50ml NS to a closed system
* Musculoskeletal Management - Abductor pillow at all times; AROM of bilateral upper extremities
* Comfort Management - 3 comfort measures

CP #1 – Impaired Physical Mobility r/t loss of integrity of bone structures aeb limited range of motion
Goal:
Pt will be repositioned once during PCS this is an intervention not a goal.....
Interventions:
1. Reposition the patient with abductor pillow maintained
2. Encourage patient to perform AROM exercises with upper extremities

CP#2 - Risk for Injury r/t confusion
Goal:
Patient will remain free of injury during PCS
Interventions:
1. Maintain SR x2 at all times
2. Re-orient to time place and events

CP #1 – choose as priority - rationale – physical mobility is a basic physiology need according to Maslow, if the patient is not able to move, tissue perfusion will be impaired, muscular skeletal contractures or atrophy may develop, strength will diminish and patient will lose ability to perform ADLS.

Documentation
Fluid management/irrigation:
Patient’s skin turgor on chest good what is good??? tinting or non tinting, oral mucosa moist and pink, accepted 120 cc water during pcs. #16 French Foley catheter patent ; irrigated with 50 cc mls...NS with cloudy dark amber urine returned to closed drainage system, no mucous plugs noted. Aseptic technique maintained. Patient tolerated without any complaints of discomfort.
Safety:
Bilateral side rails up, bed in low position, TEDS maintained Oriented patient to surroundings and instructed to use call light for assistance.but did you leave it in reach? Patient verbalized understanding.
Mobility/Musculoskeletal Management;
Physical Therapy not present during PCS. Repositioned on left side with pillows propping patient off buttock, Abduction pillow maintained. Good good???? proper alignment maintained. Patient tolerated procedure with no distress noted or verbalized. Wiggles toes, good good????? less than 3 seconds capillary refill bilateral toes, sensation present to light touch. Pedal pulses strong present or absent bilaterally. Skin of bilateral lower extremities warm and dry.
Comfort Management:
Repositioned with patient how, where??? verbalization of comfort, back rub given, and face washed. Patient verbalized appreciation and stated feels better .put what they say in quotes

Sunday, June 20, 2010

CPNE Study Guide 16th Edition page 472

JG DOB 9/14/37

DX unstable angina, DVT right leg

Information only: renal failure with kidney transplant, telemetry. Left arteriovenous shunt

Safety – siderails x2

No BP, IV, blood draws in Left arm

Mobility-

Bedrest with BRP

Reposition x 1 during PCS

Elevate legs on 1 pillow

Fluid Management-

I & O

Parenteral: 5% Dextrose in water 50 ml/hr ICD

Enteral: Fluids ad lib

Diet: regular with no added salt

Vital Signs: temporal artery temp, apical pulse, BP, Respiration, O2 Sat: report if <92% to primary RN

PVA – lower extemities

Skin assessment – lower legs

Medications:

Cellcept 250 mg po 0830

Protonix 40 mg po 0830

Lasix 40 mg po 0830

Potassium Chloride 40 meq po 0830

Comfort Management – comfort measures

K pad to right calf



Care Plan

#1 ND Ineffective Tissue Perfussion – peripheral venous r/t dx Deep venous thrombosis AEB edema, patient complaints of pain



Goal: patient will have palpable pulses during pcs.



Interventions: 1- peripheral vascular assessment

2- report any deviation form baseline to primary RN



#2 ND Impaired physical mobility r/t DVT AEB {This is a treatment and not a symptom (defining characteristic) of the nursing diagnosis.} forced bedrest



Goal: patient will assist with repositioning once during pcs



Interventions: 1- encourage patient to assist with repositioning

2- elevate legs on 1 pillow

CP for knee replacement

Hello Victoria, please excuse the late response. I do not regularly do the message center and I overlooked this request. Dr. A sent me a reminder..

Ms. Vicki Ledel is a 52 y/o female admitted four days ago for a right knee replacement due to aseptic necrosis of the lateral condyle. Her surgical procedure was uneventful. She is currently on a continuous passive range of motion machine (CPM). Ice is being applied to her right knee for 30 minutes three times a day. Her dressing remains intact with no new drainage. Her IV antibiotic has been discontinued and she is now receiving oral antibiotics. She is on a regular diet and tolerating food well. She is taking in adequate fluids and urinary output is quantity sufficient. She is presently having regular BMs, but her elimination is being monitored closely, as she is taking Lortabs 5mg po Q4 hours prn for pain (and has been taking them Q4 hours while awake). Physical therapy has made an initial assessment. Two-person transfer and limited weight-baring with a walker has been initiated.
Overriding/Required Areas of Care:
* Safety/Other (SR up X2, eyeglasses, dentures, TED hose bilateral lower extremities continuous)
* Mobility (Transfer OOB to chair with assist of 2 and walker, limited weight-bearing of right leg; elevate RLE while OOB)
* Vital Signs (BP, AP, RR, T, Pain)
Selected Areas of Care:
* Peripheral Vascular Assessment (lower extremities)
* Muskuloskeletal Management (AROM of LLE, PROM of RLE; CPM to bilat legs while in bed; Cold application to right knee X 20 minutes)
* Pain Management
* Respiratory Management (cough/deep breathing)

Care Plan:

#1 Ineffective Airway Clearance

R/t retained secretions this is a sign and symption - on page 174 under related factors, obstructed airway retained secretions is listed as r/t. Due to intubation a post op patient most likely has some retained secretions? I am confused as to why this is not acceptable.you have correctly stated this, and the text supports your choice

AEB ineffective cough this is a restatement of the NrDx review this diagnosis in the text( ackley) on page 174 defining characteristics “absent or ineffective cough” is written. Aren’t the defining characteristics the AEB? Abnormal breath sounds are the next grouping on that page. - What you are hearing is abnormal breath sound – which is the most objective data to support that the coughing is ineffective. And your interventions also support this as your evidence ( defining character istic) and your evaluation of the whether the coughing was effect would be if the breath sounds clear – otherwise there is no objective data.

Goal:

Patient will demonstrate effective cough during PCS this is anevaluation of the intervention not a goal that will assist the phyisological function of the patient. You would also have to measure “ effective”.. how would you do this? Thinking about this may actually give you your outcome. Once again on page 174 Client outcomes “demonstrate effective coughing and clear breath sounds” If I add the clear breath sounds would that suffice? As to how to measure effective? A strong vs weak cough?

Interventions:

1. Assess lungs

2. Have patient perform deep breathing and coughing exercised



#3 Impaired physical Mobility

R/t loss of integrity of bone structure

AEB limited range of motion

This one is stated correctly

Goal:

Patient will have complete ROM of lower extremities during PCS- not realistic for this patient/ what type of ROM/ how do you measure ‘complete” I intended to say - the patient will have the prescribed range of motion exercises completed during the PCS, poor wording

Interventions:

1. Encourage patient to perform AROM of LLE

2. Perform PROM of RLE



I selected #1 as my priority – this is good – as oxygen is important According to Maslow an effective airway clearance Oxygen exchange is a basic physiological need, effective airwary clearance is needed to support this exchange. Without adequate clearance of the air way the paitent may ...................with an effective airway the patient will progress towards healing as the tissue will have adequate oxygenation thus promoting regeneration.

PCS #1

This is one of the scenarios from Chuck. I am going to write out each step as though it were a real PCS. I will submit it to EC for evaluation and will post the feed back in a future post as well as an edit or possibly a comment.
36 year old female s/p cholecystectomy 2 days ago. Right abdominal incision with DSD. JP drain in place, being removed after lunch. Indwelling Foley catheter. Fluctuating pain levels 5-9 on a 0-10 scale and maintains morphine PCA at this time.

Siderails x2

VS - TPR, BP Pain level 0-10 scale

Fluids - IV D5LR @ 120ml/hr

I&O

Mobility - ambulate in hall x1 assist, OOB to chair ad lib

AOCs:

Respiratory Management - IS x 10 every hour

Abdominal assessment

Comfort Management

Wound Management - DSD to abdominal incision

CP
#1 Acute Pain r/t tissue trauma aeb pain rating of 5-9 on scale of 0-10
Goal:
 Patient will report pain level of 3 or less on a 0-10 scale
Interventions:
1- assess IV site and patentcy of PCA
2- report break though pain to RN

#2
Ineffective airway clearance r/t retained secretions aeb weak cough
Goal
Patient will perform IS 10x every hour during pcs
1-Assess lungs immediately before and after IS
2 Encourage patient to perform 10 reps of IS every hour

Saturday, June 19, 2010

Care Plan Scenarios by "Chuck"

This is an intro to a page of care plans I found on Dave's blog - It has numerous scenarios for practice care plan writing.

Greetings!

Below is a compilation of the practice scenarios I posted over the last few months. Please feel free to use these for practice. I wish you all the best in your preparation for the CPNE.

-Chuck

Care Plans are here -Click

Friday, June 18, 2010

De-Stress Kit for the Changing Times

We all know that millions of people are experiencing extra stress. Much outgoing care and compassion is needed to help ease the emotional pain that so many are increasingly experiencing. Doc Childre, founder of HeartMath, a leading stress research institute, has written a free booklet De-Stress Kit for the Changing Times that provides a few simple practices to help people intercept and manage stress during this period of challenge and uncertainty.

De-Stress Kit

The State of Ease

The State of Ease


There is a "state of ease" that each of us can access to help release emotional turbulence and help maintain coherent alignment between our heart, mind and emotions. Learning to access our personal space of "inner-ease" can be done with minimum practice and in just a little time. When operating in an ease-mode, it’s easier to choose less stressful perceptions and attitudes and re-create "flow" in our daily routines.
Click for free PDF Download

Tuesday, June 8, 2010

Apical Pulse

If you would like to know precisely where to place your stethoscope for an apical rate and would like some prctice counting irregular and infant apical rates try visting this link APICAL PULSE

Monday, May 31, 2010

video
I am trying to do the "ribbon method. I am not sure if this is the ribbon or if I discovered something else? Either way I know it is not passable and as far as technique, it is not meant to be critiqued. I reuse my supplies to help with costs. My main goal with this was to see if I have the ribbon method correct, and if this is an acceptable technique to pack the wound.

Friday, May 28, 2010

1st video wound attempt

Well I got the camera - $34 at Walmart. I did the very thing I failed for - did not change my gloves after deciding I was not getting the gauze to fit right. Of course I could have discarded the gauze and changed gloves and started again but I want to see how the video looked, check if we were getting the best view. Actually this makes the studying and practice kind of fun. Don't laugh, we are going to try a better shot tomorrow. I also have to figure out how to post the video. This picture was the best I had for tonight, unfortunately not good enough. Good thing I have a couple of months to practice.


Tuesday, May 25, 2010

Plan of Attack

In an effort to quell my nerves I have signed up for PALS and ACLS. I figure that will get me used to an examiner looking over my shoulder and critiquing everything I do and I will have to verbalize each algorithm, I don't think it can get any more stressful than that - comparatively speaking.

Monday, April 5, 2010

Care Plan Scenarios By Chuck

I am adding this link for quick access to lots of practice scenarios for care plan critique.
Chuck's Care Plan Scenarios

Friday, April 2, 2010

I was surfing the net looking for additional resources and found one of the best yet. This was written by 2 excelsior grads to share with others totally free. Here is the link. http://allnurses.com/distance-learning-nursing/cpne-notes-ec-308371.html I hope everyone else finds this as helpful and informative as I did. Many thanks to Ivan and Lisa for posting this on the allnurses.com forum.

Monday, March 22, 2010

Documentation Tips

If you do your grid from your cardex and perform your interventions make notes that you can understand . When you are out of the patient room. start at the first system and document every thing you did, do not leave out anything, think of the mneumonic for the area of care and write what you did to met that requirement. For example it you have a Enternal Feeding - RAT FEVER is the Mneumonic


R-ecord

A-mount

T-ype

F-owler position

E-xamine gastic tube/abdomen

V-erify placement verify G tube placement by aspiration contents of instillin 20 cc of air bolus and listening

E-xpiration date of formulat

R-ecord rate in first 20minutes - a patient that has fluid running must be part of your 20 minute check,

Hope you find this helpful.

Sunday, March 21, 2010

CPNE SIM LAB #4 Successful Wound Management

For successs at the Wound Station follow these steps:

ID patient against the treatment record - verbalize the patient's name, date of birth, and medical record number
Gather supplies
Ask where the location of the biohazzard container is - if possible make sure you will not have to cross your Sterile field to dispose of the drsg.
Tear tape - hang from the table edge - 3 or 4 strips
Label one end of tape with date, time, and your initials
Open all of the sterile supplies you will need
Open the Saline - do not set down the cap, pour a tiny amount in trash can
Keep label up pour saline over tub of 4 x 4 (not too much)
Don clean gloves
Loosen tape toward wound.
Remove drsg as one unit
State noting drainage
Discard in biohazzard container (DO NOT CROSS STERILE ITEMS OR YOU WILL HAVE TO DISCARD AND START FRESH)
Apply sterile gloves
Obtain one 4x4, squeeze extra saline out and open all the way do not shake
  • Parachute Method -  grasp the 4x4 in the center and bring up each corner like a parachute scrunch into smaller form , place in center of wound and open carefully; do not touch the skin with the gloves or the gauze or
  • Ribbon Method - grasp one corner of the 4x4 , fan fold (do not twist or it will become a rope and that is forbidden) and go around edges of the wound ;do not touch the skin with the gloves or the gauze
If you contaminate the gauze change your sterile gloves; Show the CE to avoid having to remove the dressing at the end and risk moving out of place.


this one would fail the gauze is too close on the left upper aspect.

Place dry 4x4 on top
Place abd on top
Secure with tape
Clean area and remove gloves
Verbalize washing hands prior to picking up pen to document
Sign the treatment record
State patient tolerated the procedure without incident
Declare completion

CPNE SIM LAB #3 Successful IV Secondary Med

To be successful at the secondary medication station follow the following steps:

Read the MAR
Calculate drip factor on the SIM LAB Recording Form (SLRF)
volume x drop factor/minutes - gtts/minute
Record the flow rate (gtts/min) for 15, 30, and 60 seconds
Obtain the correct medication bag from the selection
ID against MAR - verbalize to CE - Patient name, Date of Birth, and Medical Record Number
Don clean gloves
Inspect IV site - verbalize no edema, site dry, no sign of infiltration
Remove gloves
Clamp tubing of both primary and secondary fluid
Drop Primary Bag
Spike medication bag
Check for air in tubing - prime if needed
Open secondary med all the way
Adjust the rate using the clamp on the primary line
Verify rate with CE
Don gloves and check for infiltration after CE verifies gtts/min
Sign MAR and
Declare end

CPNE SIM LAB #2 IM/SQ Injection

For the successful IM/SQ Injection follow these steps:

Read the MAR
Note time, drug, dose, route on the MAR
ID the patient name, Medical Record Number, Date of Birth against the MAR
Select medications from assorted vials and correct syringe/needle from assortment of syringes/needles
Calculate the amount of each medication to be given

DESIRED/ON HAND

Record individual and total volume on Simulation Laboratory Recording Form (SLRF)
Cleanse top of vials with alcohol
Draw up air in to syringe for each medication and show CE
Inject air into vial second medication(NPH) first then first medication(REG)
Invert vial and draw up first medication and show CE
Invert second vial and draw up second medication without allowing air into syringe
Show CE for verification
Re-cap using scoop method
Don clean gloves
ID Patient to CE - verbalize name date of birth and medical record number from band and MAR
Identify site for injection
Cleanse area with alcohol useing circular motion inside to outside
Insert needle bevel up with dart like motion
Aspirate for IM
Inject slow and steady
Withdraw needle and dispose in the sharps container
Apply light pressure to area unless heparin or insulin
Remove gloves
Wash hands (verbalize washing hands in SIM LAB)
Record medication on MAR





CPNE SIM LAB #1 Successful IV Push

The successful sequence for the IVP is

Read the MAR
Get the Med
Do the math

Clean the top of the med bottle
Label 3 empty syringes
Draw up med and put the med bottle to the side
Clean the top of the NS bottle
Draw up the 2 flushes witht the amount stated in the MAR

ID the patient - Name, Date of Birth, Medical Record Number
Glove with clean gloves
Inspect IV site - verbalixe not edema/swelling/redness
Wipe IV Port
Aspirate patency

Flush the IV with NS over 8 - 10 seconds
Give med over the ordered time frame
Flush with NS over 8 - 10 seconds

Sign the MAR
Declare you have finished and acknowledge completion of all of the critical elements for this station.

Do this and you will pass the IVP
One LAB down 3 more to go.

Friday, March 19, 2010

Back for round two

Okay now that I wallowed in misery for the last week it is time to get back to business. I am setting up the grandkids' room again as my SIM LAB. I believe you can never practice too much.

HINT - To save cost I reuse my drsg supplies. The glue stick works pretty good at sealing the paper, good to do this to keep you in the habit of opening the packages and maintain sterile technique.

I will be posting more mneumonics as I come across them. I sincerely hope this helps someone on the same journey.

Monday, March 15, 2010

Horrible News

I failed this weekend at Gwinnett. I am so dissapointed I can not put it into words. However, I will not give up. I will go back even stronger, I really need to learn so type of stress management that really works. I am not too good at the meditation thing, New at it may be the reason. I could do the wound with my eyes closed and failed it - nerves the second time for sure but questionable the first. I am appealing.

Be ready for a really long wait and no lunch bring cash for the vending maching for drinks - no water fountatins where I was.. More later......... Vickie

Wednesday, March 10, 2010

Care Plan Tips from Sheri

I attended the CPNEworkshop.com in Atlanta the end of January. I had not done a real care plan - ever. I had just learned about NANDA labels while preparing for the Nursing theory exams in August. Sheri and Gregg had wonderful tips and made it understandable.

  • When selecting your careplan remember The basic physiological needs, Maslow Hiearchy is good.
    • ABCs  = Airway, Breathing, Circulation, Safety (pain is at the top also)
  • You have to have one actual problem (or they would not be in the hospital). The second one can be either an actual or risk for problem.
  • You must have a goal the begins with "the patient" and ends with during my PCS (to make it measurable)

Tuesday, March 9, 2010

Advice for Nerves

"How many times have you expressed anxiety & disgust concerning CPNE prep or performance and some ----- has told you to try meditation? Probably a few. In light of the fact that many suggest meditation but leave it up to the recipient of the advice to figure the rest out I thought I would run through a basic meditation practice that might be helpful.

Find a straight back chair or a big cushion to put under your butt while you sit cross legged on the floor. Put your hands on your knees with your finger tips lying just over your knee caps. Put your elbows out a little and make your back straight. You can just lie down on your back but being upright usually works out better.

Don’t be concerned with what you’re mind is doing and just spend a few minutes watching what your mind is up to from you’re unique vantage point. Listen to the pleasant, reassuring sound of your breathing. Now forget about what you’re mind is doing and concentrate on your breathing. Nice, slow, deep breaths in through the nose and out through the nose. Touching the roof of your mouth with the tip of your tongue makes this feel more natural.

Do that for a couple of minutes. Then do this. Pretend, just imagine, that your breath is going all the way down to right behind your belly button like there is a little pipe going there and you are just concentrating on your breath slowly coming in, settling behind your belly button, resting there, and then rising again to start over.

Now this is where it gets really weird. Imagine, your imagination is a tool for you to use, that you are surrounded by a very gentle but strong blue energy. Kind of like when the energy monster from the old Star Trek attacked except this energy is benevolent. Take a minute or three to get this image strong in your imagination. This energy is peace. You know it from balls to bone. Inhale this peace and let it settle behind your belly button before you exhale. Every time you inhale see yourself in your imagination filling with this cool blue energy until, after a little while, you are full of peace. Every time you exhale send a little thanks and gratefulness out to the universe or God or Isis or Jesus or Buddha or Vishnu for being so cool and letting you hang out and experience life.

If you enjoy that there are a lot of neat things along those lines that are very helpful and effective. A book by this guy named Robert Bruce called Energy Work is very cool. If your path is Christian you may also enjoy a little book by a man named Thomas Keating called Centering Prayer."

This is an except from Dave's CPNE study guide blog. He has lots of good tips, mneumonics, and quotes from conversations with an EC advisor.

Check out Dave's CPNE Study Blog

nursesaregreat.com - Brush up on Your Drug Calculation Skills

nursesaregreat.com - Brush up on Your Drug Calculation Skills

This is a wonderful refresher for those of us that get lazy and rely on computers and pharmacist.

Monday, March 8, 2010

Lung Assessment

Lung Assessment

I don't think we need to assess all of the positions but it doesn't hurt to know. There are recordings of lung sound here also.

Grammarly

Grammarly
This is a great tool for papers and reports.

Sunday, March 7, 2010

Irrigation

Irrigation
  1. Selects the designatied solution
  2. Determines the appropriate temperature of solution when neccessary
  3. Positions the patient to facilitate irrigation
  4. Verifies the correct placement of the tube
    • if a nasogastric tube by aspirating gastric content and
    • if a nasogastric tube by instilling 10-20 cc of air into stomach while auscultating (5 cc for children under 2 yearsof age
  5. Instills the solution into the designated area
  6. Controls the rate of flow of the solution
  7. Postions the receptacle for the return flow
  8. Records the kind of irrigationg solution used
  9. Recourds the amount of irrigation solution used

Local Palm Coast Blogs - Palm Coast, Florida, USA

Local Palm Coast Blogs - Palm Coast, Florida, USA

Enteral Feeding

Enteral Feeding - From Excelsior College Flash Cards - 2005
  1. Complies with established guidelines
  2. For all feedings:
    • selects the prescribed feeding
    • positions the patient to promote feeding
    • delivers the prescribed feeding
  3. When assistance with feeding is designated:
    • chooses an appropriate feeding device
    • burps an infant under 6 months of age periodically as necessary
  4. Administers the feeding at room temperature unless otherwise designated
  5. When intermittent tube feeding is designated
    • determines the amount of feeding to be administered
    • calculates the drops per minute
    • verifies the location of a nasogastric feeding, unless contraindicated by
      • aspirating gastric contents and
      • instilling 10-20 ml of air into the stomach while auscultating (5 ml for children under 2 years of age)
    • measures gastric residual before initiating feeding
    • reinstills gastric residual unless contraindicated
    • initiates the prescribed feeding within +/- 30 minutes of scheduled time
    • regulates the feeding rate to be delivered within the specified time when required by either
      • adjusting the flow rate to within +/- 5 gtts/min of the calculated number of gtts or
      • adjusting the flow rate of the enteral feeding pump to the exact number required to deliver the prescribed volume
  6. When continuous tube feeding is designated:
    • Within twenty minutes after beginning the Implementation Phase
      • Verifies the accuracy of the flow rate by either
        • counting the gtts/min currently flowing or
        • documenting the flow rate setting on the enteral feeding pump on the PCS Recording Form
      • Regulates the flow rate when required by either
        • adjusting the flow to within +/- 5 gtts/min of the calculated number of gtts/min or
        • adjusting the flow rate of the enteral feeding pump to the exact number required to deliver the prescribed volume
      • Verifies the location of the nasogastric tube at least once during the PCS by the following methods, unless contraindicated by
        • aspirating gastric contents AND
        • instilling 10 - 20 ml of air into the stomach while auscultating (5 ml for children under 2 years of age)
      • When measurement of gastric residual is designated
        • measures gastric residual
        • reinstills gastric residual unless contraindicated
        • determines the amount of feeding to be administered
  7. Records the kind of oral feeding administered
  8. Records name and strength of the feeding product for a patient receiving a tube feeding
  9. Records the amount of feeding administered
Mneumonic

RAT FEVER

Record
Amount of formula AND
Type of formula
Fowler's position to receive tube feeding
Examine gastric tube/abdomen
Verify placement - Verify G-Tube placement by aspirating gastric contents OR instilling 20 cc air bolus and listenting
Expiration date of formula
Record rate in 20 MINUTES!! - a pt theat has running tube feeding IS PART OF YOUR 20 MINUTE CHECKS!

Drainage and Specimen Collection

Drainage and Specimen Collection - from Excelsior College Flash Cards 2005
  1. Complies with established guidelines
  2. When drainage collection is assigned:
    • assess the amount and color of drainage
    • cleans the surounding skin or tissue when assigned
    • inserts the tube into the appropriate body cavity
    • when drainage is by tube:
      • maintains or attaches tube to container
      • maintains patency of the tube
      • maintains drainage by gravity or suction apparatus
    • removes the tube when assigned
  3. When specimen collection is assigned
    • obtains the designated speciment
    • places the specimen in the designated container or on the designated surface
    • ensure that specimen is labeled
    • places speciment in designated area for transport
  4. Records data related to drainage amount and color
  5. Records data related to specimen collection
  6. Documents and/or reports disposition of specimen

Selected Areas of Care - Wound Management

Wound Management
  1. Complies with established guidelines
  2. Assesses wound location, type, appearance, and presence or absence of drainage
  3. When irrigation is designated:
    • selects the designated solution
    • determines the appropriate temperature of the solution (approximate)
    • uses an appropriate irrigation delivery system
    • positions a receptable for return flow
    • irrigates without contaminating the wound
    • protects the surrounding skin from contact with the drainage
  4. Cleanses the wound with the designated solution
  5. Applies the designated topical preparation
  6. When wound protection is required
    • removes the dressing without contaminating the wound
    • removes the dressing without injuring the surrounding skin
    • disposes of the soiled dressing in the designated container
    • applies the dressing without contamination the wound
    • secures the dressing
    • labels the dressing with the date, time, and their initials
  7. Records
    • Data related to wound
      • location
      • type
      • appearance
      • presence or absence of drainage
    • measures implemented to cleanse, irrigate, and protect the wound and surrounding skin
    • patient response to measures implemented

Selected Areas of Care - Respiratory Management

Respiratory Management
  1. Complies with established guidelines
  2. Positions the patient to facilitate respiratory hygiene activity(ies)
  3. Provides a receptacle to receive secretions as needed
  4. Assesses the patient's respiratory status before initiating respiratory hygiene activity(ies) by:
    • instructing the patient specifically to breathe in and out as deeply as possible moving the stethoscope from side to side
    • observing breathing patterns
  5. Directs the patient in or performs one or more respiratory hygiene activity(ies):
    • Deep Breathing
      • instructs the patient specifically to breathe in and out as deeply as possible
      • repeats deepbreathing exercise as ordered or as indicated by the patient's condition
    • Coughing:
      • instructs the patient specifically to breath in and out deeply
      • instructs the patient specifically to cough forcefully on third or fourth expiration
      • provides for splinting, whiile the patient is coughing, if necessary
    • Mechanical deviceds, such as those used for inspiratory spirometry, etc.
      • instructs the patient specifically to use the device
      • repeats respiratory exercise as ordered or as indicated by the patient's condition
    • Chest Percussion
      • claps the designated area(s) of the chest wall vigorously with cupped hands, unless contraindicated
      • vibrates the designated area(s) of the chest wall vigorously, unless contraindicated
    • Suctioning
      • when suctioning by catheter is assigned
        • verifies patency of the catheter
        • sets the pressure on the suction machine as designated
        • inserts the catheter before suctioning
        • rotates the catheter continuously during suctioning
        • suctions for no more than 15 seconds at a time
        • repeats as necessary to remove secretions or
      • when suctioning with a bulb syringe is assigned:
        • deflates the bulb syringe prior to insertion
        • inserts the bulb syringe into the patient's mouth and/or nares before suctioning
        • aspirates secretions
        • repeats as necessay to remove secretions
  6. Reassesses respiratory status immediately after respiratory hygiene activities
  7. Records
    • bilateral breath sounds heard after treatment in comparison with those heard initially related to each of the above assessment findings
    • abnormal breathing patterns
    • respiratory hygiene activities implemented

Selected Areas of Care - Pain Management

Pain Management
  1. Assess the patient's level of pain by:
    • Asking an adult to rate level of pain using a 1-10 scale or visual analog scale or
    • Asking a child 3 years of age or older to rate level of pain using a 0-5 faces scale or age-appropriate visular analog scale or
    • Using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age or
    • Observing behaviors indicative of pain in a patient unable to rate his/her pain (e.g. moaning, grimacing, cltching, restlessness)
  2. Administers pain medication(s), when assigned
  3. Reports the patient's level of pain to the assigned staff nurse
  4. Provides one of the following relief measures:
    • repositions the patient or assists the patientto a different position
    • gives the patient a backrub
    • uses relaxation an/or distraction techniques
    • applies heat or cold when assigned
  5. Reassesses level of pain by:
    • asking an adult patient to rate level of pain using a 0-10 scale or visual analog scale or
    • asking a child 3 years or older to rate level of pain using a 0-5 faces scale or age appropriate visual analog scale or
    • using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age or
    • observing behaviors indicative of pain in a patient unable to rate pain level (e.g. moaning, grimacing, clutching, restlessness)
  6. Records
    • patient's level of pain
    • pain relief measures implemented
    • patient response to measures implemented
Mneumonics

PRN

Pain scale 0-10
Reposition, relaxation (there are other things you can do to alleviate the patient's pain level, but this part of the "R" is a reminder for you to do something for the patient's pain)
Need to reassess

Fluid Management Mneumonic

"Hello - I use the mneumonic Won't I Be Glad I Prayed On This Day Saints Forever.

Wash hands in front of CE
Introduce and instruct pt of plan
Band check with MAR
Gel and glove up
IV site check
Pinch and palpate site
Off with the glove and GEL
Tubing check
Drip rate
Solution
Fluid level -state out loud to CE

**always GEL and document at the end of everything."

Carla Danz 3/6/10

IV PUSH

STATION 4: IV PUSH

MNEUMONIC: Clean Label Clean - FIGIWA - Flush Give Flush


6 ETOH PADS && 2 PAIR GLOVES


STEPS: *** MED -> MATH -> MAR ***


Right: Medication/Dose/Route/Time & Date/Exp Date/Allergies/Patient)


*** WASH THY HANDS BEFORE STARTING ***

Clean - Clean top of medication bottle.

Label - Label 3 empty syringes (2 NS & 1 Medication)

Clean - Clean NS port on bag

F - Draw up the two flushes && medication. (Med/Exp Date of flush bag)

I - Id the patient.

G - Glove up with non-sterile gloves

I - Inspect the IV site - "NO EDEMA"

W - Wipe IV port with alcohol

A - Aspirate - "I SEE A BLOOD RETURN" "** UNCLAMP TUBING **

Flush - Flush with NS

Give - Give medication over prescribed time (slow is better).

Flush - Flush

*** DO NOT TOUCH INSIDE STEM OF PLUNGER ***

*** CLAMP TUBING AND SIGN THE MAR ***

ERRORS:
1. Timing of push -- Easy to push much too fast.

2. Air bubbles -- Need to look carefully for air bubbles. Did not see bubble next to rubber part of plunger. Easy to get rid of bubble, but also easy to not see bubble.

3. Plunger stem -- ** THIS IS EASY TO FORGET **
-- Do not touch stem of plunger. Need to really watch this.

4. Backflow clamp -- Unclamp backflow clamp before attempting first flush.
-- Clamp backflow clamp after completing second flush.


OTHER: 1. Syringe package -- Open syringe packaging all the way. Just do it.

2. Syringe plunger -- Loosen up syringe before using.

3. Syringe type -- Watch 3cc vs 5cc syringes. You may be pushing more than three cc of medication. (per instructor)

4. Flush bag -- Verbalize "Zero point nine percent sodium chloride".

-- Verbalize "Expiration date"

-- Do not say "Normal saline" <-- This per instructor.

4. Pain relief -- You may sit down to do this station.

John Coxey (Syracuse, NY)