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
  • 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

  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


  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