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)

Saturday, March 6, 2010

Nursing Fundamentals ii Multimedia Edition - Introduction

Nursing Fundamentals ii Multimedia Edition - Introduction
This site has video of many nursing fundamentals that you already know, but may want to confirm you are in fact doing it the right way.

Wound Dressing

A Post from the EPN discussion Board

- Welcome to your new friend, the CPNE Wound from Hell.

- I use the ribbon method for packing the wound. There is a video or two showing how to do this type of a packing on YouTube.

- I tried the parachute method ... it's too complicated for me. Then again, I can't fold my own dress shirts either.
---------
- Ok. Trick here is, unfold the gauze all the way (you already knew that).

- Next. Fold the gauze (lengthwise) one time, in the middle.

- Next. Lay the gauze in your hand ... really gentle like. Do not squeeze. You want it sort of "fluffy."

- Next. With the end of the gauze sticking out of your hand ... you want to fold back (over itself) about 1/2 inch of that end. You can twist the end if you need too. This will get rid of the little strings at that end.

- Note: Do not make the entire gauze into a "rope." Just the 1/2 inch of your starting piece, so you can get rid of your strings and also get the first corner packed.

- Next. Place that tiny twisted piece in one of the corners. Bingo!!! You've now packed one corner.

- Next. Play out the gauze from your hand. You want

to keep it about 1/2 to 1 inch wide. Then use your index

finger to guide, pack the wound. I go from one end of the wound to the other ... back and forth.

- If you do this right, you will have plenty of gauze for the packing.

- Practice using no gloves. Note: Reusing the same piece of gauze will eventually cause it to become frayed and you'll get 100's of those little strings. Also, watch the boat, as it will get mildew after a week. I learned the hard way.

-You need to practice the wound about 30 minutes a day.

- Just practice the wound packing at first. Yes, you will throw the wound across the room many times. It happens. But, eventually, you will get good at packing the puppy.

- Watch your knuckles, and your thumbs. They seem to come "loose" when you focus on the dressing and not your hands. Knuckles and thumbs hitting the skin seem to be the next hurdle with this puppy.

- Also, copy and paste pictures of the Excelsior Wound on the wall in front of your dressing. It's fun to compare your "masterpiece" to that of the CPNE guidebook.

- Hope this helps.
John Coxey
(Syracuse, NY)

CPNE FAQs

Subject: CPNE FAQs Topic: CPNE (FAQs)


Author: DARREN WALSH Date: July 31, 2009 8:49 AM

This is a post from Excelsior about the CPNE



FAQS!!! – CPNE

PLEASE NOTE that the questions and answers are also available in a PDF format at the end of this message so you can print them out or save them to your computer.



1. What is included in the 20 minute check?



The 20 minute check occurs after implementation begins, and is preceded by the overriding area of care Asepsis (SG pages 117-119) Caring (SG pages 124-130. This pertains to fluids that are entering the body by intravenous method or enteral feeding and includes: Fluid Management critical element 3 a 1,2,3,4. Also, reference on SG pg. 113



2. Do I have to reidentify the patient each time I leave and enter the room?



No. Identifying the patient MUST occur two times during the PCS: 1. in the area of care Caring (SG p. 124, critical element 1 A,B,C,D, before beginning any required or selected areas of care, and 2. prior to entering the selected area of care medication (SG p. 285) critical element 4 a,b,c. You must also re-identify the patient if you have to hang a new IV bag.



3. Where can I put the paperwork during the PCS?



You could keep it in the pocket of your uniform top or pants. Additionally, the clinical examiner will be able to answer your question as to where to place it if this is not an option.



4. Must there be a barrier between my paperwork and any surface in the room?



No. The clinical examiner will be able to answer your question as to where to place the paperwork in the room.



5. When does Caring come in? Each time I leave and enter the room?



Caring is an overriding area of care (SG pages 124-130.) If you are referring to identifying yourself, the examiner, and the patient, this is done at the beginning of implementation, upon first entering the room. If you are asking about the other critical elements listed in caring, they are to be carried out throughout the PCS and will be evaluated by the clinical examiner. This includes therapeutic communication (element 2), verbal and physical expressions, as well as respect for the client (elements 3, 4 and 5).



6. When can I change a diagnosis to AT RISK and must I use the revised form to do it?



You are not required to make any change to your nursing care plan once the clinical examiner has reviewed it and accepted it in planning. However, should you choose to do so, you may do that at any time during the PCS, once you have determined that the patient’s condition warrants it. (SG pages 112 – 113) At that time, you must show the changes to your clinical examiner by writing them on the revised form, found behind your evaluation phase form in your kardex. Be sure to copy those areas you did not change to facilitate the examiners review of what was changed. The CE will then use the planning phase criteria to re-evaluate your plan.



7. If I have washed my hands, do I have to wash them again after identifying the patient before putting on my gloves to check the IV site?



No. You are expected to wash your hands in order to protect others, yourself and the environment from contamination. No contamination occurred (SG p. 119).



8. Do I have to wash my hands when I take my gloves off after checking the IV site and before touching the tubing?



Yes. The guidelines in the SG pages 120-122 use this as an example. Think about going from a dirty to clean area. The potential exists for contamination from the IV site.



9. For fluid management, how do I convert popsicles and ice chips to fluids?



In many hospitals, there is a conversion sheet that will be provided to you by the clinical examiner. The rule of thumb is one cup of ice chips (a cup that measures 240 ml) is equal to 120 ml. The popsicle wrapper may also provide you with the volume. When in doubt, ask the clinical examiner or staff nurse.



10. What type of fluid is included in intake and output?



Intake you are responsible to record includes: All fluids consumed during the PCS, including the fluids on the breakfast or lunch tray, or what has been taken in during the one hour you have been assigned to measure intake for hourly intake. The volume of the primary IV fluid infused during the PCS when the primary IV fluid has totally infused and the next ordered solution is hung, the IV orders are discontinued, or the patient is on hourly intake; the volume of a secondary IV when it has fully infused. When output is designated, you are to collect and measure all output. Output to measure may include urine, liquid stool, emesis, and chest tube drainage and/or wound or nasogastric secretions. (SG p. 161)



11. Must I keep track of everything that goes in?



Yes, if intake has been designated. (fluids) (SG p. 160)



12. When do I mark the bag so I know what I am responsible for as IV intake?



Page 157 in the study guide states that the student is to determine the amount that is in the bag at the beginning of implementation with the CE. When a new IV needs to be hung, the CE will indicate this in writing on the PCS assignment Kardex. (SG p. 158)



13. How will I know that the CE and I are on the same page for fluids in the bag if I have to change it?



(see above, same answer)



14. When assigned output for children, will I include stool?



Page 162 of the study guide states “Check with the assigned nurse to learn whether formed stool is weighed with the diaper.” On some hospital units the formed stool is removed prior to measuring the diaper weight.



15. When assigned output for children, what if the stool is liquid?



When measuring all output, page 161 of the study guide states: Output to measure may include urine, liquid stool, emesis, chest tube drainage, and/or wound or nasogastric secretions.



16. When do I declare pain level assessment?



If pain level assessment has been assigned under the area of care Vital Signs, you must assess and record this under Vital Signs, and declare it when you declare Vital Signs. (SG p. 176) If you are assigned pain level assessment under the area of care Pain Management, (SG p. 236) you do not have to declare pain level and will be recording it in the narrative notes under Pain Management.



17. What if I am not assigned pain management, will I still have to let the staff nurse know if the number has changed?



Yes. Study Guide pg 176 states: If pain is assessed as part of Vital Signs, and you are not assigned the area of care Pain Management, you are still responsible for intervening in the management of your patient’s pain by reporting the pain level to the staff nurse if indicated.



18. If my diagnoses have changed from planning, can I wait until evaluation to change it if I did the interventions I planned?



Yes. You may change your diagnoses any time during the PCS, including evaluation. (SG pages 112-113). Study guide pg 314 also states: If needed, you may write an entirely new nursing diagnosis and address this as a priority problem in evaluation. Any interventions that are written either in planning or revised during implementation or evaluation must be performed.



19. Do I need to reassess lungs after each intervention (during Respiratory Management), or only at the beginning and end?



The study guide, page 253 states: Immediately following completion of all assigned respiratory hygiene activities, reassess respiratory status with patient in the same position as during initial assessment.



20. Do I have to tell the examiner when I am performing skin turgor assessment or assessing peripheral pulses?



You do not have to verbalize what you are doing to the examiner, however, study guide pg 152 states: Since the assessment of hydration status may be done unobtrusively, be obvious in your actions when performing this assessment and verbalize your findings to alert the CE that you are completing the critical elements. The same is true for pulses.



21. When performing an abdominal assessment, do I have to interrupt the tube feeding?



The SG p. 181 states to turn off the suction machine while auscultating bowel sounds, however, there is nothing to indicate the need to interrupt the tube feeding.



22. If the patient has a nasogastric tube, can I put them flat to do the abdominal assessment?



Yes. If the patient is on suction, you must turn off the suction while auscultating bowel sounds, however, there is nothing in the study guide to support not putting them flat. (SG p. 181) If the patient has a tube feeding via a nasogastric tube, you cannot put them flat, but must keep the head of the bed elevated at least 30 degrees.



23. If the patient is on continuous suction, do I need to interrupt the suction to listen to bowel sounds?



Yes. (See above explanation)



24. If I forget to do a part of an area of care, can I go back into the room during evaluation and if so does the 20 minute check start again?



You may go back into the room if you recognize that you have forgotten something during evaluation. The “20 minute check” only related to fluids in the beginning of implementation. (SG p. 113) You can only be evaluated once on any critical element, therefore, there would be no reason for redoing this check



25. How many repetitions must I do when assigned ROM? The text reference says 3-5 and the study guide states 1.



Study Guide page 220 states: When ROM is designated, you will be expected to direct or assist the patient to perform at least one pair of the following movements: abduction and adduction; flexion and extension. All joints of the designated extremity (ies) are assessed.



26. Is it OK to put tabs in our care plan book and medication book and write what area the tabs are indicating? Can we do this before coming to the CPNE?



Yes.



27. Is it acceptable to highlight our kardex in order to keep us focused during the PCS?



Yes. Some students create their organizational plan on the Kardex as well.



28 . If the clinical examiner indicates one area to assess under skin assessment, do we have to choose two more?



No. Study guide, p. 208 states: Assess a minimum of two vulnerable skin surfaces from the list. You must do two. (the study guide does not state that the Clinical examiner may assign one and you have to choose one more, nor does it state that if the examiner does not indicate any but assigns skin assessment, you will choose two).



29. When may I identify the patient at the lab stations that require identification?



The study guide states, in the simulation lab (pages 359, 361, 370, p. 379) you are to identify this “patient:” immediately before administering the medication.



Attachments: CPNE_FAQS_updated.pdf;









Messages in the thread Display Complete Thread

Name Author Date

CPNE FAQs DARREN WALSH July 31, 2009 8:49 AM

Selected Areas of Care - Oxygen Management

Oxygen Management - from Excelsior College Flash Cards 2005
  1. Assesses the patient's response to activity level
  2. Assesses oxygenation status by
    • inspecting nailbeds for color, capillary refill, or clubbing or
    • measuring oxygen saturation level when assigned
  3. Assesses skin surfaces in contact with oxygen delivery system
  4. Positions the patient to facilitate respiration
  5. Sets, adjusts, or maintains oxygen flow at designated rate (liters or percent)
  6. Maintains humidification of oxygen if humidification is present
  7. Removes articles, if present, which can produce a spard or flame from bedside area
  8. Applies, inserts, or maintains device to deliver oxygen, at the designated rate when required
  9. Applies and maintains instrument to measure oxygen saturation level when assigned
  10. Records
    • data related to each of the above assessment findings
      • response to activity level
      • oxygenation status
      • condition of skin surfaces in contact with oxygen delivery system
    • oxygenation management measures implemented
    • patient response to measures implemented
Mneumonics

SOAPI

Skin assessment around ears and nares
Oxygen saturation/flow rate/percentage
Activity tolerance
Postion to facilitate respirations - pattern of respirations
Ignition sources

Selected Areas of Care - Musculoskeletal Management

Musculoskeletal Management
  1. Assess the affected area of designated extremity(ies) for:
    • presence or absence of abnormalities (e.g. atrophy)
    • level of mobility
    • pain with movement
  2. Directs the patient to move the joints of the designated extremity(ies) through active range of motion by including at least one pair of the following:
    • abduction and adduction or
    • flexion and extention OR
  3. Performs passive range of motion by
    • moving the joints of the designated extremity(ies) though range of motion at least once by including at least one pair of the following:
      • abduction and adduction or
      • flexion and extention
    • supporting the weight of the extremity at joints during range of motion
  4. Applies supportive or therapeutic devices to the designated body part(s)
  5. Applies heat or cold when assigned by
    • protecting the skin surface of the body part to be treated
    • applying treatment to the designated body part to be treated
    • applying treatment at the designated temperature (approximate)
    • maintaining treatment for at least 20 minutes unless otherwise designated
  6. Maintains prescribed traction by
    • verifying the prescribed traction weight
    • assuring that ropes are unobstructed
    • assuring theat weights are hanging freely
    • positioning the patient to provide countertraction
    • maintaining the patient in the correct alignment
  7. Records
    • data related to
      • presence or absence of abnormalities (e.g. atrophy) of the designated extremity(ies)
      • level of mobility of the of the designated extremity(ies)
      • pain with movement of the designated extremity(ies)
    • musculoskeletal measures implemented
    • patient response(s) to measures implemented
Mneumonics -

BEAMR MAP

Balance
Extraneous movement
Assistive devices
Moved where
Response
Movement
Abnormalities
Pain

MAP HATR (think of a muscular mad hatter from Alice in Wonderland)

Mobility status
Abnormalities
Pain with movement
Heat or cold
Apply devices (like knee brace) if needed
Traction - just make sure the lines are unobstructed, weight hans free
Range of motion - passive or active as directed by CE


    Selected Areas of Care Comfort Management

    Comfort Management
    1. Assess comfort needs by
      • Asking the patient to describe confort needs or
      • Observing behaviors indicative of discomfort
    2. Provides three of the following comfort measures:
      • assist the patient with washing face, hands, and/or vulnerable skin surfaces
      • repositions or assists the patient to a different postion
      • gives the patient a backrub
      • uses relaxation and/or distraction techniques
      • applies heat or cold when assigned
      • assists the patient with mouth care
      • changes or adjusts bed linens
      • administers medication(s) when assigned
    3. Records
      • data related to comfort needs or disconfort
      • comfort measures implemented
      • patient response(s) to measures implemented
    mnemonic - COMFORTERS

    Comfort measures  - do 3
    Oobserve for discomfort
    Meds - PRN
    Face wash
    Oral care
    Relaxation
    Treat with heat or cold
    Evaluate comfort at end
    Reposition
    Simple back rub

    Selected Area of Care - Skin Assessment

    Skin Assessment

    1. Based on your patient's condition, assesses a minimum of two vulnerable skin surfaces for the list:
      • heels
      • sacral/coccyx
      • occiput
      • trochanters
      • skinfolds
      • peri anal
      • designated area(s)
        • for -
          • color changes
          • integrity (e.g. lesions, ras, shear and pressure effects, skin tears)
          • temperature
          • edema
          • moisture (e.g. perspiration, incontinence, diarrhea, non intact ostomy/drainage system)
    2. Records assessment data of two vulnerable skin surfaces including any designated area(s) related to:
      • color changes
      • integrity (e.g. lesions, ras, shear and pressure effects, skin tears)
      • temperature
      • edema
      • moisture (e.g. perspiration, incontinence, diarrhea, non intact ostomy/drainage system)

    Mneumonic -
    TIME to check Color of skin

    Temperature
    Integrity
    Moisture
    Edema

    Color

      Selected Areas of Care - Respiratory Assessment

      Respiratory Assessment RN CEU Link 
      Respiratory Assessment

      1. Complies with established guidelines
      2. Positions the patient to faciliatate assessment
      3. Assesses the patient's respiratory status by
        • Instructing the patient specifically to breathe in and out as deeply as possible
        • Auscultating breath sounds over upper and lower lobes by systematically moving the stethoscope from side to side
        • Observing breathing patterns
        • Meassuring oxygen saturation, when assigned
      4. Records data related to
        • Comparison of breathing sounds bilaterally
        • Abnormal breathing patterns
        • Oxygen saturation, when assigned
      Mnemonics -

      PAIR of lungs (respiratory assessment)
      Position patient
      Assess the rate rhythm, accessory muscle use, and pattern
      Instruct to deep breath
      Record

      HAIR, or pair of hairy lungs (respiratory managgement) you must do the respiratory assessment first
      How did the patient tolerate deep breathing?
      Always perform deep breathing and cough
      Incentive Spirometry (if assigned)
      Re-assess after deep breathing/cough/IS

      If you are assigned oxygen management -

      SOAPI (soapy tire with air bubbles coming out the top)
      Skin assessment - check the skin around the canula, face mask, ears, nose...is it red? intact?
      Oxygen status - O2 saturation or capillary refill
      Activity level - assess patient's response to activity, tired? short of breath?
      Postion patient to help facilitate breathing
      Ignition sources

      Selected Areas of Care - Peripheral Vascular Assessment

      Peripheral Vascular Assessment

      Peripheral Vascular Desease this will take you to a wonderful learning resource with pictures of various things you will be assessing for and what it means.

      1. Complies with established guidelines
      2. Compares the extremities by all of the following:
        • Palpating for the presence or absence of the most distal pulses
        • comparing the most distal corresponding palpable pulse(s)
        • Assessing perfusion of extremity(ies) by:
          • checking capillary refill or
          • observing color
        • Assessing for temperature of extremiy (ies)
        • Eliciting the pateint's response to tactile stimuli applied to the distal portion of the extrmity (ies)
        • Assessing motor function by
          • asking the patient to move extrmity (ies) or
          • noting movement of the extrmity (ies) in a child under 3 or a non-communicating adult
      3. Records data related to bilateral comparison of extremities:
        • Presence or absence of the most distal pulses
        • Capillary refill or color
        • Temperature of extremity (ies)
        • Response to tactile stimuli
        • Motor function
      "Please Make Sure To Chart"
      Pulse
      Movement
      Sensation
      Temperature
      Capillary refill or Color

      Selected Areas of Care - Neurological Assessment

      Neurological Assessment
      1. Complies with established guidelines -
      2. Assesses the patient's level of consciousness by
        • Asking specific questions to determine orientation to all of the following:
          • Time
          • Place
          • Person OR
        • Determining the patient's ability to recognize familiar people or common objects in the environment OR
        • Presenting visual, auditory, and tactile stimuli to a child between 1 and 3 years of age or a non-communicating child or adult
      3. Palpates the anterior fontanel of a child under 1 year of age, with the child in an upright position, unless contraindicated
      4. Assessess pupillary response regarding
        • Equality of pupil size and
        • Reaction to light
      5. Assesses equality of the motor response in upper and lower extremities in a responsive patient by
        • Asking the patient to
          • use both hands to squeeze your hands simultaneously and
          • Dorsiflex or plantarflex both feet simultaneously agains resistance OR
        • Observing musculoskeletal response(s) in a child under 3 years or noncommunicating child or adult for
          • Symmetry and
          • Movement
      6. Assessess the patient's response to a noxious stimulus when the patient is nonresponsive to verbal stimuli by applying pressure to a nailbed
      7. Records data related to
        • level of consciousness
        • assessment of fontanel
        • assessment of fontanel
        • pupillary response
        • equality of motor response or observation of musculoskeletal response
        • response to noxious stimuli
      Nursing Neuro Assessment Refresher
      Nursing Care for Neuro patients
      Neuro Assessment

      Neuro Assessment -
      Adults - COPS Make Nice CAMP for kids

      Consciousness
      Orientation
      Pupils
      Sensation
      Movement
      Noxious Stimuli

      Consciousness
      Assess Fontenel
      Movement
      Pupils

      Selected Areas of Care - Abdominal Assessment

      Abdominal Assessment
      Check this site for an abdominal assessment - there are 43 slides with way more information than you will need, however it will not only instruct you how to do a proper assessment it will help you understand the underlying process as to what your assessment indicates.

      Critical Elements for the CPNE include:
      1. Complies wsith established guidelines
      2. Positions the patient to facilitate abdominal assessment (supine with legs slightly bent)
      3. Inspects for distention
      4. Ausculates for bowels sounds
      5. Performs light palpation over all 4 quadrants for tenderness or rigidity, unless contraindicated
      6. Measures abdominal girth, when assigned.
      7. Records data related to:
        • distention
        • presence or absence of bowel sounds in each of the four quadrants
        • tenderness or rigidity
        • abdominal girth, when assigned
      • 4 Ps
        • Pee - ask patient if they need to urinate
        • Pain - ask if in any pain
        • Position - lay flat with knees slightly bent
        • Privacy
      • Look - Listen - Feel

      Friday, March 5, 2010

      Required Areas of Care - Vital Signs

      Vital Signs
      1. Complies with established guidelines
      2. Obtains accurate vital signs by:
        • Reading the instrument within a stated range of
          • +/- 2 degrees for temperature
        • Counting within a stated range of
          • +/- 5 beats for apical or radial pulse (+/- 10 beats/minute for apical pulse for a child under 2 years)
          • +/- 2 respirations/minute for adults (+/- 6 respirations for a child under 2 years)
        • Reading the instrument within a stated range of
          • +/-6 millimeters for blood presure
        • Obtaining an accurate weight, when assigned by:
          • balancing the scale
          • undressing the patient as neccessary
          • maintaining cleanliness of the scale
          • weighing within one percent (1%) of the correct weight
        • Obtaining oxygen saturation when assigned
        • Assessing the level of pain, when assigned, by:
          • Asking an adult patient to rate level of pain using a 0-10 scale or visual analog scale or
          • Asking a child 3 or older to rate level of pain using a 0-5 faces scale or age appropriate visula 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 or pain in a patient unable to rate his or her pain (e.g. moaning, grimacing, clutching, restlessness)
      3. Records each of the assigned vital signs on PCS Recording  Form

      Thursday, March 4, 2010

      Required Areas of Care - Fluid Management

      Fluid Management
      1. Assesses the hydration status of the patient by one of the following methods:
        • Checking skin turgor or
        • Inspecting the mucous membranes or
        • Palpating the anterior fontanel of a child less than 1 year of age
      2. For enteral fluids
        • Determines the kind(s) of fluid to be ingested
        • Administers or restricts fluids as designated
      3. For parenteral fluids:
        • Within 20 minutes after beginning the Implementation Phase:
          • Verifies the accuracy of flow rate by either
            • Counting the drops per minute currently flowing or
            • Documenting that the flow rate of the infusion control device is set at the exact number required to deliver the prescribed volume by writing the correct setting on the PCS Recording Form
          • Assesses the insertion site of peripheral, central, or implanted venous access devices for dislocation, infiltration, or other complications by using one of the following methods:
            • Feeling the surrounding skin for changes in temperature OR
            • Palpating the surrounding tissue for edema
          • Regulates the flow rate when required by either:
            • Adjusting flow to within +/- 5 drops per minute (regular or microdrops) of the calculated number of drops per minute OR
            • Adjusting the flow rate of the infusion control device to the exact number required to deliver the prescridbed volume
          • Records the prescribed fluid infusing on the PCS Recording Form
        • Throughout the Implementation Phase:
          • Administered the prescribed fluids
          • Administers the designated amount of fluid per hour within the following ranges (as long as this amount of error does not place the patient in physical jeopardy):
            • +/- 25 ml per hour for a patient over 2 years of age
            • +/- 10 ml per hour for a patient under 2 years of age
          • Recalculates the fow rate or adjusts the ICD settting if the physician's order changes
          • When the next prescribed primary IV fluid is required:
            • Selects the designated fluid
            • Calcuates the amont of fluid to infuse per specified period of time
            • Identifies the patient immediately before administering the IV solution by verifying two of the following peices of patient information
              • Patient name
              • Date of birth
              • Medical record number
            • Assesses the insertion site of peripheral, central, or implanted venous access devices for dislocation, infiltration, or other complications by using on of the following methods:
              • feeling the surrounding skin for changes in temperature OR
              • Palpating the surrounding tissue for edema
            • Clears IV tubing of air before initiating flow
            • Regulates the flow rate by either:
              • Adjusting the flow to within +/- 5 drops per minute (regular or microdrop) of the calculated number of drops per minute or
              • Adjusting the flow rate of the infusion control device to the exact number required to deliver the prescribed volume
            • Records on the PCS Recording Form the new fluid being administered
          • When maintenance of an intermittent venous access device is required:
            • Assesses the insertion site of peripheral, central or implanted venous access device for dislocation, infiltration, or other complications by:
              • Feeling the surrounding skin for changes in temperature OR
              • Palpating the surrounding tissue for edema
            • Aspirates for blood return unless cotraindicated
            • Flushes the intermittent access device with the designated flush solution
            • Records the flush solution on the PCS Recording Form
          • When a peripheral device is discontinued:
            • Assesses the condition of the IV site
            • Removes the cannula
            • Applies pressure to the venipuncture site
            • Applies a protective covering
      4. When enteral and/or parenteral intake is assigned:
        • Measures the amount of fluid ingested/infused
        • Records fluid intake within +/- 10% of the actual intake
        • Records kind(s) of fluid ingested/infused
        • Recouds hourly intake on PCS Recording Form within +/- 10 minutes of the designated time, when hourly intake is assigned
      5. When output is assigned:
        • Collects output
        • Measures output during the entire PCS
        • Records amount of output within +/- 10% of actual output for the PCS on the PCS Recording Foum (output from urinary retention catheters or other drainage apparatus is not measured during the PCS unless otherwise designated)
        • Records amount of hourly output on the PCS Recording form within +/- 10 minutes of the designated time, when hourly output is assigned
      6. Records data related to:
        • Hydration status
        • Condition of insertion site for peripheral, central, or implanted venous access devices

      Wednesday, March 3, 2010

      Overriding Areas of Care - Physical Jeopardy

      Physical Jeopardy

      Any action or inaction on the part of the student which threatens the patient's physical well-being. Students are accountable for the patient's safety throughout the entire PCS. Any time the physical safety of the assigned patient is threatened through ommission, such as not reporting a deterioration in the patient's clinical condition, or by an imminent incorrect action by the student, the entire PCS will be terminated and failed. This area of care is to be invoked at the discretion of the Clinical Examiner and supported by data from the clinical situation.

      Overriding Areas of Care - Mobility

      Mobility

      1. Assesses the patient for
        • level of mobility
        • use of assistive devices
        • presence of balance abnormalities
      2. 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 to a 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
        • using measures to prevent shearing of skin
      3. Assists with transfer or ambulation by
        • stabilizing equipment
        • using measures to maintain the patient's balance
      4. Records
        • data related to:
          • level of mobility
          • use of assistive devices
          • presence of balance abnormalities
        • positioning, transfer, or ambulation activities completed during the PCS
        • patient's response to the psoition, transfer, and/or ambulations activities

      Overriding Area of Care - Emotional Jeopardy

      Emotional Jeopardy

       Any action or inaction on the part of the student which threatens the emotional well-being of the patient or significant other(s). This area is invoked at the discretion of the Clincal Examiner, validated with the patient, and supported by data from the clinical situation. The entire PCS will be terminated and failed any time the emotional well-being of the patient or significant other(s) is threatened.

      Overriding Areas of Care - Caring

      Caring
      1. Establishes communication and a trusting relationship with the patient at the beginning of the Implementation Phase by:
        • Introducing self and  identifying the patient by comparing two of the following pieces of patient information against the PCS form
          • patient name
          • date of birth
          • medical record number
        • explaining the purpose of the interaction or using touch with a patient who is a child or non-communicationg adult if culturally appropriate.
      2. Uses therapueutic communication techniques consistent with the patient's level of understanding to interact with the patient and significant others by
        • encouraging the patient's expression of needs
        • responding to the patients's verbal expressions
        • responding to the patients's non-verbal expressions
        • facilitating goal-directed interactions by
          • explainging the nursing actions to be taken
          • asking questions to determine the patient's reponse to nursing care
          • asking questions to determine the patient's comfort level
          • focusing communication toward patient-oriented intersts
          • eliciting the patient's choices/desires in the organization of care
      3. Uses verbal expressions that are not overly familiar, patronizing, demeaning, abusive, or otherwise unacceptable
      4. Uses physical expression that are not overly familiar, patronizing, demeaning, abusive, or otherwise unacceptable
      5. Relates in a manner that respects the values, dignity, and culture of others

      Overriding Areas of Care - Asepsis

      Asepsis
      1. Washes hands in the presence of the Clinical Examiner before beginning the Implementation Phase of each PCS.
      2. Protects self, others, and the environment from contamination
      3. Protects the patient from contamination
      4. Disposes of contaminated material in designated container
      5. Establishes a sterile field when required