Dana Russel Warren' Notes

These the notes I used to study for CPNE…I tested under 16th editon study guide…so if your testing under 17th edition, you may have to modify them for yourself. Some of the mneumoics are from other students, some that i made up. I referenced several sources to find the 'complies with established guidelines' stuff...fundamentals book, the taylors clinical nursing skills book, wongs pediatric, and saunders NCLEX RN review. Anyways, hope it helps someone else get started!

Planning Phase:

In planning phase you must write a NCP that is congruent with standards of practice and med regimen and calculate flow rate for gravity IV, if assigned. Actual diagnosis must have etiology (r/t) and signs / symptoms (AEB) : Risk for diagnosis must have etiology only. Etiologies should not reflect a procedure, treatment, or person as cause of problem. EXP: Acute pain r/t tissue trauma vs. Acute pain r/t surgery.

R/T can be a medical dx, but it is recommend that you use nursing data…however it would not be a fail (per Civita)

Overriding Areas of Care

Caring – Intro self, explain procedure, listen to pt, theraputeic communication

Asepsis – wash hands before & after every implementation of care, PPE, able to set up and maintain sterile field. You can GREET pt upon entry to room, before washing hands ONLY.

Must wear gown when picking up infant due to risk for spitting up (body fluids), Use barrier on scale when weighing infant, child, or diaper.

• Gloves to change diaper

• If pen falls on floor, put on gloves, clean pen with wipe – off gloves & wash

• Suctioning trach – gloves, gown, mask, protective eyewear or mask

• Front of gown is contaminiated, untie first – then gloves off, untie back of gown & remove, remove mask, and wash.

Mobility – BAMMARS –

• B – balance abnormalities – balance, posture

• A – assistive devices – equipment or person used to aid in movement.

• M – mobility level – in each PCS mush assess and document level of mobility, including any condtion where mobility is impaired or restricted.

• M – move / position -

• A – assist with ambulation - stabilize equipment / assist to maintain balance

• R – response – endurance/pain/ dizziness/ dyspnea

• S – slippers before ambulation

• Record

Must move or reposition pt at least once every PCS.

Physical Jeopardy / Safety – report to RN any changes, slippers, side rails, bed low & locked, call bell in reach.

Every time you leave the room: SCABRS ( like Ron's rat on Harry Potter)

• S – Side rails x2

• C – call bell in reach

• A – ask if needs anything

• B – bed low

• R- Remind of I & O

• S- Soap – wash hands or alcohol foam

Emotional Jeopardy – do not cause emotional distress / harm to pt! Address pt as mr/ mrs - never hon / darling or anything demeaning or belittling

Mobility: Is in effect in every PCS at all times. You must move or reposition pt at least once during every PCS. If pt on bed rest, CE will have repositioning on PCS Kardex. Turning pt from supine to side for backrub, then back to supine is NOT repositioning.

You must ambulate pt if assigned. When ambulating – must stabilize equipment and assist pt to maintain balance. You may ask staff nurse or CE to help move pt.

To position “in proper body alignment” is to position so that joints are in straight line.

Required Areas of Care

Fluid management –WIG GAS REARR

W – wash hands

I – ID, Explain

G – gloves on – IV site for edema

G – gloves off – tubing for kinks / bubbles

A – assess hydration – turgor, mucous membranes or ant. Fontanel in <1

S – Solution, rate, regulate if nec by KARDEX

R – Record for 20 min check – (sol, rate, Iv Site, turgor )

E – Enternal fluids – type – encourage or restrict as per assignment

A – administer fluids through pcs within 25 ml/hr for >2 , within 10ml/hr <2

R – Record I & O if assigned type & amount within 10% of amount and if hourly within 10 min of time

R - record hydration status –iv site assessment, 20 min checks, flushes for hep/saline lock

If you have to hang new IV fluid: select fluid (NS, 1/2NS, D5W), ID pt, Site check, tubing check, regulate/rate - REcord

Hep/Saline locked IV: Aspirate, Flush, record Flush on PCS record form.

D/C IV: assess site, remove, apply pressure, covering as assigned

Vital Signs

In children, less than two, use brachial pulse. Older than 2, radial pulse. Note baseline. Apical pulse is most reliable for infants and small children. ((Will be designated on KARDEX which pulse to use))

BP: palpate brachial artery first, then place cuff on arm – inflate to 20-30mm/Hg above highest baseline systolic. Wait 1 full minute before taking second set (AHA)

FLACC – 2m-3y

Apical pulse – 5th intercostal space to left midclavicular line. Count one min.

Tympanic temp: pinna down and back for less than 3 yo, out and up for over 3 yo.

Weight: BUMW – Balance scales, Undress as necessary, Maintain clean of scale (socks, barrier for infant/child/diaper), Weigh within 1% of correct wt.

Infant/sm child – gloves/gown when weighting on lying scale.

Assessment Areas of Care

Abdominal – PPLLFR (people please, look listen, and feel, response&record)

P- pee, pain - have pt void – suction off if on suction (OBSERVE MOBILITY if up to restroom)

P – position lying flat with knees slightly flexed, pillow under knees, hands at side, not behind head

L- look – distention, shape – verbalize what you are doing

L – listen to all four quads – if don’t hear sounds immediately, start 1 min count

F- feel – light palpation in all quads, tender areas last – have pt relax – tenderness___ rigidity___

R – response of pt – record data & response

Neuro – LAPMN R (Lord Almighty, please move now – record)

L – level of consciousness – orientation to person, place, time – or ability to recognize familiar people or objects or in child l-3 or non comm. adult – provide auditory, visual, and tactile stimulation. EXP clap hands for audio, move toy/object and watch if child tracks for visual, stroke foot for tactile.

A – Anterior fontanel in upright position for under 1 -“flat” is norm, rounded, bulging, or depressed

P – PERL –assess equality of pupil size and reaction to light (Lights out - ask CE for penlight)

M – Motor response equality – have pt squeeze nurse hands simultaneously and dorsiflex or plantarflex both feet simultaneously or in children under 3 or non comm. adult, observe both symmetry and movement.

N- noxious to nailbed - assess pt response to noxious stimulus when pt is unresponsive to VERBAL STIMULI by applying pressure to nailbed.

R – response / record data r/ LOC, fontanel, PERL, equality of motor response, response to noxious if applicable.

Exp: patient alert and oriented to person, place, and time. PERL, Hand grasps and plantar flexion against resistance strong bilaterally and equal. No paresthesia. Verbalization clear and understandable.

Pt oriented to person and place, disoriented to time. Left pupil smaller than right, both brisk in response to light. Moves all extremites spontanesouls with equal streath bilat hand grasp and plantar flexion against resistance.

Infant active and alert; responds to parents, verbal, and tactile stimuli with cooing. Ant fontanel soft, slightly rounded. PERL, both eyes track light. Moves all four extremities equally and spontaneously.

EXP of asymmetry – such as paralysis (sagging of muscle of face – is important assessment finding

Respiratory Assessment – PILLOR (Pillor treatment lol )

• P – Position – sitting upright if able, side lying if cannot, or over anterior chest wall if unable to turn or sit.

• I – Instruct to breathe in and out as deeply as possible.((assess for dizziness))

• L - Listen over posterior upper and lower lobes, over intercostals spaces, systemically side to side to compare lung sounds, with stethoscope directly on skin. Use bell of stethoscope to auscultate in peds pts…can use diaphragm if you can hear.

• L - look – Observe pt’s breathing pattern (rhythm, depth, and use of accessory muscle

• O – O2 sat if assigned

• R – response / record comparison of breath sounds bilat as clear or abnormal, abnorm breathing patterns, 02 sat if assigned.

Peripheral Vascular Assessment – PMS-CT

• P – Pulses – most distal pulses, compare bilaterally – Doppler will be avalible if needed.

• M – motor function by asking pt to move the extremity (s) or noting movement in child less than 3 or non communicating adult.

• S - Sensation to touch on distal portion of extremity (s) – ask if feels touch on toes/finger

• C - capillary refill or color observation -- cap refill is preferred

• T – temperature of extremity (s)

• R – Record presence or absence of most distal pulses, cap refill or color, temp of extremity (s), motor function, response to tactile stimuli.

Arterial / Venous insufficiency

Arterial – pulses diminished, no edema, cool temp, pain, intermittent claudication, decreased sensation, tingling

Venous – present pulses,, edema that improves with elevation, norm – warmer temp, pain decreases with elevation & exercise, may have pruritus

If pt has TEDs on, remove & assess, then replace TEDs. (CPNE Chat 7/6/10)

Possible ND: Ineffective Tissue Perfusion r/t compromised blood flow AEB pale, cool extremities --- Goal: pt will cooperate with tx plan to improve circulation --- NI: keep legs dependent with arterial insuffiency or elevation with venous insuff. NI 2: perform PV assessment of extremities.

Acute pain r/t decreased tissue perfusion aeb pain of 7 on 0-10 scale –

Risk for peripheral neurovascular dysfunction

Goal – pt will have cap refill less than 3 sec in both feet NI – Assess cap refill in toes of both feet --- NI 2: Elevate L leg on one pillow above level of heart

Skin Assessment- CITEM - for 2 vulnerable skin surfaces

• C – Color changes

• I - Integrity – lesions, bruising, rash, shears, skin tears, ect

• T - temperature

• E - edema – presence or absence

• M – moisture – perspiration, incontinence, diarrhea, non intact ostomy/ drainage system

• R - record assessment data

Skin Surfaces: heels, trochanter, sacral / coccygeal , occiput, skin folds, peri anal, designated area/s

Checking bilateral heels / trochanters/ ect would be only 1 surface, would have to do another area also

Management Areas of Care

O2 management – ASS PRESHR

• A – activity tolerance – observe pt for SOB, DOE after repositioning, ambulation, or participating in activites…may also observe pt for changes in vital sigs such as pulse / resp rate after activites.

• S – status of o2 – cap refill, clubbing, or o2 stats if assigned

• S – skin surfaces in contact with O2 – nares, behind ears for redness/irritation

• P – position pt to increase oxygenation

• R- rate of O2 , adjust / maintain

• E – equipment insert, maintain, or apply as needed and assigned

• S – safety from sparks

• H – humidify if assigned – add water if needed to maintain – as ordered

• R – reassess/ response / record

In all PCS with Ox management – assess O2 status and response to activity – position, rate of delivery, and maintain humidification if needed.

ND – Impaired Gas Exchange r/t ventilation & perfusion imbalance AEB O2 Sat of 89%

NG- Pt will have O2 sat equal to 98% on room air.

NI – Monitor O2 on room air

NI - Place pt in upright position

Pain Management – PMRRRR

• P – Pain Level

• M- Medicate if assigned

• R – Report level of pain to staff RN if not assigned meds

• R – Relief by one: reposition, backrub, relaxation/distraction or heat/cold application(if assigned)

• R – Reassess in 20-30 minutes- have pt remeasure level of pain

• R – Record pain level, pain relief measure implemented, and pts response to measures.

ND: Acute pain r/t tissue trauma AEB pt verbalizing pain, rates 7/10

Goal: pt will rate pain 3/10 or less during PCS

NI: Reposition pt to increase comfort

NI: Have pt rate pain 20 min after pain relief measures implemented

Acceptable levels of pain during evaluation:

0-10 Pain Scale for Adult PT: 3 OR LOWER

0-5 Faces Scale *3 and older: 2 OR LOWER

FLACC Pain Scale for 2 months- 3 years: 3 OR LOWER

Dr .A & Civita say to think of it as both the FLACC and the 0-10 pain scale of going to 10, so 3 or less is acceptable – Faces scale is 2.

Respiratory Management – PILLOR + RIRR

• P – position - upright / sidelying if upright contraindicated

• I - instruct to breathe in and out as deeply as possible _ ask about dizzy____

• L – listen over checst – POSTERIOR recommended byECE due to clearer sounds - directly on SKIN – COMPARE side to side – Make sure you don’t listen over bony prominence or nonlung area = fail!!!

• L – look – observe breathing patterns – before any hygiene – establish your baseline while breathes in & out as deep as possible.

• R – Record baseline (write down so don’t forget anything)

• R – Receptacle

• I – Intervention on KARDEX - Deep breathe , coughing, Mechanical devices such as ins spirometry, chest percussion, suction by catheter or by bylb syringe. **

• R – Reassess IMMEDIATELY and in same position as first assessment after respiratory hygiene activites –

• Record!! Record bilateral breath sounds heard after tx in comparison with those heard initially, abnormal breathing patterns, resp hygiene implemented, pt response to resp hygiene,

**Deep breathing : Instruct pt to breathe in and out as deeply as possible, repeat deep breathing exercises as ordered or indicated by pt condition. Assess for dizziness with deep breathing.

**Coughing: Instruct pt specifically to breathe in and out as deeply as possible

Instruct pt to specifically cough FORCEFULLY on THIRD or FOURTH EXPIRTATION.

Provide SPLINTING while pt is coughing if necessary

**Mechanical Devices such as used for inspiratory spirometry, ect:

Instruct pt how to use the device

Repeat as ordered or as indicated by pt condition

**Chest percussion: Claps the designated areas of chest wall vigorously with cupped hands unless contraindicated. Vibrates designated areas of chest wall vigorously unless contraindicated.

**Suction: Verify patency of catheter, set pressure on suction machine as designated, insert cath BEFORE suctioning, rotate cath continuously during suctioning, Suction no more than 15 sec at a time, repeat as necessary to remove secretions.

**Bulb suction: deflate bulb before insertion, insert into mouth or nares before suctioning, aspirate secretions, repeat as necessary to remove secretions.

ND: Ineffective Airway Clearance r/t increase secretions or inability to mobilize secretions

Impaired gas exchange r/t ______

Musculoskeletal Management – MAP R HAT R

• M – mobility level

• A – abnormalities / contractures – presence or absence

• P – pain with movement – observing or asking in rom, repositioning, ambulating, ect

• R – ROM – active or passive – flex / ext or add/abd – major joints of assigned extremity(s) ~ do not have to do if on CPM -

• H – heat or cold if assigned – PART time (20min)

• A – apply therapeutic / supportive devices to assigned body part(s)

• T – Traction (WAPM – weights (amount and hanging free) Assess ropes (unobstructed, no linens touching, not frayed) Position pt for countertraction, maintain pt in correct alignment

• R – Response / Record – record presence or absence of abnormalities of designated area, level of mobility to the extremities, pain with movement of extremities, measures implemented and pt response to measures.

Therapeutic/Supportive devices may include: CPM machines, splints, braces, antiembolism stockings immpblizers, sequential compression stockings

Perform assessments ONLY on designated extremity (ies) – CE will have on Kardex exercises or devices to be applied or tx to be maintained. Do only what you are assigned to do.

Impaired Physical Mobility r/t musculoskeletal impairment AEB unsteady gait

Goal: Pt will ambulate safely to end of hall and back

Intervention 1: Provide non skid slippers

Intervention 2: Assist pt with ambulation as needed

Wound Management – WICTD – R (well, I’ve changed two dressings, really)

• W – Wound Assessment – location, type, appearance , presence or absence of drainage

• I – Irrigation if assigned – sol, temp, delivery, receptacle, don’t contaminate, protect surrounding skin. SIPP ( Sol&temp – Irrig deliv system____. Position receptacle – Protect skin )

• C – Cleanse wound with designated solution

• T – Topical prep applies as designated

• D – dressings – remove old without contaminating wound, properly dispose of, place new properly without contaminating, date, time & initial

• R – Response and Record: wound location, type, appearance, drainage, measures implemented and pt response to measures implemented.

Wound types: laceration, contusion, abrasion, puncture, laceration, penetrating wound, pressure ulcer.

Appearance: observe wound bed, granulation, necrotic, any drains in wound, s/s of infection, inflammation, condition of surrounding skin – When assessing for infection, note redness, odor, pain, and warmth.

Drainage –

• Serous – thin, watery

• Sanguinous – bloody

• Serosanguinous – serum & blood mixed

• Purulent – containing pus, indicative of infection

Comfort Management

• A – Assess comfort needs by asking patient to describe comfort needs or by observing behaviors that indicate discomfort

• I – Implement 3 of 8 comfort measures

1. Assist with washing hands, face, and/or vulnerable skin surfaces

2. Repositions or assist to diff position – if ambulated under mobility – it would count – document that got pt up & ambulated, repositioned in bed following ambulation.

3. Backrub

4. Relaxation or distraction techniques

5. Assist with mouth care (GLOVE up first)

6. Change or adjust linens

7. Administer med if assigned

8. Apply heat/cold therapy if assigned

• Reassess/ record

Changing diaper of infant is assisting with washing vulnerable area, holding an infant or placing in an infant seat or high chair are appropriate methods of repositioning a baby. Mouth care – if under 4 yo, CE will designate equip to be used for mouth care – distracters such as playing, singing, listening to music, giving pacifier, favorite blanket or toy, may also promote comfort.

Other Areas of Care

Medication – WATCH MARS

1. W – Wash hands

2. A – Aquire meds, checking by MAR

3. T – Take MAR + Meds to pt room

4. C – Clean hands (wash or alcohol)

5. H – Have gloves if needed (sq, im, ivpg,optic, ect)

6. M – MAR to ID pt

7. A – Assess as needed (PTT / bleeding for heparin, BP for BP med, HR for dig, Resp for MSO4, ect)

8. R- Recheck meds & give

9. S – sign MAR

If your giving IV fluid or PGGY – make sure to assess IV site and ID immediately before gibing med, even if these checks have been done earlier (such as in 20min checks)

Record ML/HR or GTT/MIN on PCS record form BEFORE giving.

Hep/Saline locked IV: Aspirate, flush, give, flush, record flushes on PCS form.

If you will be adjusting dose at bedside, let CE know this or it will be a med-error.

If A&O – may ask pt to state name / DOB , compare to MAR – must be done immediately before giving meds _ pg 286 study guide - can compare ID band/MAR in non-verbal, confused

Can ask parent to ID child – if small infant, child – no ID band – check crib to see if it is on crib.

Patient Teaching – LEARN

1.L – Level of readiness to learn

2.E –Evaluate pt’s learning need (“what can you tell me about why you are taking this medication?” “What foods would you avoid while talking this medication?” How will you know it’s okay to take your digoxin at home?”

3.A- Accurate information r/t need is provided

4.R – Reassess understanding

5.N – Need to ask questions to determine understanding

Pt teaching will be co-assigned with another AOC. Will be brief and basic centered around pt disease process, self care needs, medical tx and should be consistent with co-assigned area of care. We can use unit procedure manual, unit teaching handouts, and drug books as resources (pg 299 of study guide). You are not required ot provide new info, you can clarify info that was previously taught to reinforce content.

Drainage & Specimen Collection - DC CATS OPEN


2. C – Color, Consistency, & Amount

3. C- Clean skin if assigned

4. A- Appropriate cavity (for tube)

5. T- Tube removal if assigned


7. O – obtain specimen

8. P – place in appropriate container / location

9. E – ensure label is on specimen

10. N – need to take to area for transport

Could be assigned to insert Foley, monitor drainage from NG tube, wound drain, fecal collection container, or other collection device. Will not be rewired to insert NG tube.

Irrigation – SIP TIP CR

1. S – solution & temp

2. I – ID pt / PPE

3. P – position pt

4. T – tube placement

5. I – instill solution

6. P – position receptacle

7. C – control rate

8. R – response / record area irrigated, amount & type of solution used and pt’s response

Whether or not irrigation is included in I & O is per hospital policy. Ask about policy – primary RN or CE.

Record pt response to procedure – ASK pt!

Enternal Feeding

Evaluation – go with priority ND, can be actual or risk…explain why you picked as primary nursing diagnosis. Review NI, evaluate as effective or not effective. It’s okay if not effective! Just give a suggestion for a effective intervention. Write notes. Review.

Labs – You can write mneumonics on paper you use to do math on! (CPNE Chat 7-6-10)

Wound – Tina A Friendly Nurse Got In Good Shape Running Track

1. T – tape – initial, date & time

2. A - abd

3. F – 4x4 + tub

4. N – NS in tub

5. G – gloves – sterile and clean

6. I - ID pt

7. G – gloves (clean) on – remove old dressing, verbalize

8. S – sterile gloves – pack wound

9. R – remove gloves

10. T – tape

IV Push – Some Really Drowsy Dragons Imagine Goats And Penguins Finding Silver

1. S – Select med

2. R – record

3. D – draw flushes (2), make sure to clean port/vials

4. D – draw med – clean vial with alcohol pad

5. I – ID pt by MAR

6. G – gloves on, and clean port

7. A – aspirate before first flush

8. P – push med over given time, do not go fast, may go slower

9. F – flush

10. S – sign Mar

IV Med – Swine cloaked in colorful robes stole Tommy’s loot. Foolish, piggies run very slowly.

1. S – select med

2. C – calculate and record

3. I – Id pt

4. C – clean gloves & check IV site for edema

5. R –remove gloves

6. S – spike bag with clamps closed

7. T – tubing for bubbles/kinks

8. L – lower primary bag below secondary

9. F – fully open secondary clamp

10. P – primary clamp opened slowly to regulate

11. R – regulate within 2-3 gtts, hand off clamp, count 1 min

12. V – verify rate

13. S – sign mar

14. Tell CE have completed crit.elem

IM/SQ Injection – Some Really Rough Cowboys In Gowns Play And Sing

1. S – select med

2. R -record

3. R – roll NPH

4. C – clean vials

5. I –ID pt by MAR

6. G – gloves on, find/clean site

7. P – pinch or tense

8. A - aspirate

9. S – sign mar