W Wash hands
I Id pt/self/CE
G glove up
S start 20min checks
20 minute checks:
1. assess IV site (document on recording form) *take off gloves/wash hands
2. verify IV flow rate (document on recording form)
3. Document current IV fluid type running on PCS recording form
*continuous enteral feeding is treated just like an IV
(check for placement with air/asp)
H hydration check and discuss I&O’s
I IV site check/remove gloves/wash
C check tubing
R record on PCS form
("hi crater", like jumping into the big hole of the PCS journey)
Med calculations: Aretha Franklin: What you want / baby I've got it x ml
(dose to give) / (dose on hand)
ex. Give 25mg of Benadryl, preparation is 50mg in 1 ml
25 / 50 + 0.5 x 1 = 0.5ml to give
1. write mneumonic on sheet during IVP station, check off when done
2. Put a "A" on one of the saline syringes pkgs to remember to aspirate
3. overdraw saline and med and then waste what you don't need, less bubbles
4. SCDIGAS: Select med, calc dose, draw up med, Id pt, glove up/check IV, asp/flush/med/flush, sign mar
5. take your time with IVP, 1min push can go over the desired time
TSOIGRSPRT: (To soon or I grasp it, right?) Tape, supplies, open, Id pt, glove, remove dsg, sterile gloves, pack wound, remove gloves, tape
*pack loosely, and don't move it around once it is in, don't press down on 4x4 over wound
1. SCIGCLTRS: (speed cleaning I get clutters) Select med/mar, calc dose, Id pt, gloveson/check IV/gloves off, clamp and spike, lower primary, tubing check, regulate gtts, sign mar
1. IM/subq: SCRCIGPAS: (score/cig/pas) “score a cigarette and pass it on” select med, calc dose, roll nph/draw meds, clean vials, Id pt, glove up, pinch/tense, aspirate, sign mar
*If it is IM choose the vastus lateralis and know the proper landmark, to aspirate, the needle to choose, and to aspirate and massage gently.
*Ventrogluteal is the preferred site
*Do not remove Lovenox air bubble
*Insulin syringes (50units goes up by 1, 100units goes up by 2)
Correct needle size
IM 1-1.5 in 21-23 gauge
SQ 5/8 inch, 25-29 gauge
Read the entire study guide at least twice (once at the beginning and towards the end).
Learn the mnemonics for all AOC and Labs.
Take a workshop or put into practice what you have learned (follow along with Rob if you can't do a workshop).
Learn careplanning and documentation: post on EPN for review and then send them into Dr A through the EC messages.
Take an online conference. Best one if only taking one: EC skills conference
Set up phone conferences for answering questions
1. Don’t spend a lot of time in the planning phase. Just pick some sort of reasonable
Nursing Dx and Interventions quickly. You will have limited knowledge of the patient and you will probably have to revise any Nursing Dx and interventions anyway. Do your thing in Implementation and THEN allow what you’ve already done to direct you in choosing a priority Dx and Interventions during the Evaluation Phase.
2. In Planning Phase, don’t spend too much time with the Kardex or the chart. You will learn so much more directly from the patient and it will save you time. You can always look something up later if needed. You don’t need to know everything about the patient.
3. i did spend time during my planning phase, drafting up a grid. this will be your point of reference throughout your PCS. if your grid isn't complete, you will more likely not fulfill all the areas of care and ce's.
4. The CE will get the staff nurse when they are available. You should begin your careplan as soon as the assignment has been read to you, and timing begins. You could begin with your grid, or your careplan, and when the staff nurse gets to you, she or he will give report.
5. You do not wait until the CE accepts your careplan. Please read the planning phase critical element explanations again. You are on a time limit! Civita Nurse Faculty
1. Do the Implementation Phase in phases. Leave the room for 15-20 minutes at least once to catch up on planning, thinking and documenting as you go.
2. Document on your grid as you go along and transfer to your PCS recording form later. 3. Group Patient care activities, and remember Assessments and Managements don’t all have to be linear. Do bits and pieces as opportunities present.
3. If during Implementation, the CE interrupts and asks, “Have you completed the Critical Elements for blah blah assessment/management?” Immediately say, “No, I would like to review my papers.” Then, think madly and try to figure out why they asked you that. If they ask this, it may mean you are about to fail and you may have a chance to correct your mistake if you can figure out what you missed. They will NOT ask you this question if you are doing everything correctly.
4. when doing pt id prior to assessments, verify your pt with the PSC response form kardex
Hello Mr. Smith, my name is __________ and I am a nursing student through Excelsior College and this is also my instructor, "Ms. straight face". First off, I would like to check your armband and verify your name and DOB. I wanted to thank you for allowing me to care for you this morning, I understand many people come and go in your room during a typical day and this opportunity means a lot to me. I have a few things I need to do this morning, take your vital signs, listen to your lungs and see how your incision is healing. I also have some medications due at 0900 I will be bringing in. How does this sound? Great! And, how are you doing this morning? Anything that you would like to address or any concerns? Ok, I would like to check your IV so I will need to wash my hands and glove up first......
*address pt as Mr. or Mrs. unless told otherwise by pt
*report off to nurse any improvement or deterioration of pt's condition
*r/t is never a procedure, tx or person. However the use of a medical diagnosis as the etiology is acceptable (pg 309 SG)
*During Evaluation and Documentation, check your grid against your PCS recording form at least 3 times before turning in. Make yourself a system for marking off your grid as you go and then as you document. One student my weekend failed a PCS for not documenting pain of 0, even though the CE and the student both knew she assessed the patient’s pain at least 5 times during Implementation. If it is not documented, it wasn’t done.
*The pt's responses provide evidence supprting an 'effective intervention' decision. the statement must be the pt response you observed or data you collected.
Rationale example from SG pg 311: Acute pain
Control of pain is a basic human need. If pain control is not adequately managed, the pt may be hesitant to fully participate in the tx plan, which could lead to a complication such as pneumonia that might then delay healing and prolong hospitalization.
(notice only one complication needed, pneumonia) KISS
ex. Priority ND: Acute Pain related to tissue trauma aeb pain rated 7/10 on 0-10 verbal scale.
Goal: the patient will report pain 3 or less on 0-10 scale
Progress: met- patient reported pain 2/10 on 0-10 scale
NI1. Assess level of pain-
Effectiveness-effective: patient rated pain 7/10 on 0-10 scale
NI2. Administer prescribed analgesic
Effectiveness-effective: patient reported pain 2/10 on 0-10 scale 30 mins after Lortab
*Nicole quote: Like others said, you would mark effective and then state instructed pt on IS and pt performed the IS x 10 breaths without difficulty. The CE/CA's were very particular on the patient response at my site. make sure you state something you saw, heard, or felt!
*Civita: Remember the response is the outcome which you received from the intervention, or the outcome you wanted to achieve overall. You would write Pt instructed to deep breath and cough, effective, pt;s lung sounds clear (Look at your goal - the effectiveness would be how this intervention moved them toward it, and ties in together.
THE KARDEX IS YOUR CARE PLAN. Don’t get creative. You need two nursing diagnoses, one actual and one can be a risk for, with two interventions. They need to be measurable within the PCS. So you will always be assigned mobility. It is marked to get the patient who had a left hip replacement OOB to the chair with 1 assist. Your diagnosis is “Impaired mobility related to limited weight bearing on left leg as evidenced by need for 1 assist to move from bed to chair.” CHOOSE FROM THE KARDEX. The Kardex IS your care plan in sensible terms we all understand. Your nursing diagnoses must be supported by the evidence and you will NOT need any of, as one of my older instructors called them, the “high-falutin’ ones that I don’t know how they came up with them.”
1.Asthma, sob, 02sat(assigned), dyspnea on exertion, abdominal surgery, copd, =Activity intolerance
2. Hx of falls, or need assistance with ambulation,
=Risk for injury
3. reddened heels, red butt, red groin
=Impaired skin integrity
4. fluctuation of 02 sat
= impaired gas exchange
*Do not use generalized weakness unless it does exist. Last time, as lisa S said, look at your AOC and work backwards as far as care plans,
Resp. management: Ineffective airway clearance, Ineffective breathing pattern
PVA ineffective tissue perfusion
*Remember AEB is what you hear, see or feel(civita)
*Do not just get stuck on the admitting dx, LOOK AT THE AOC ASSIGNED,
Nsg. dx = Mosby gives you
R/T(cause) admitting or you tailor to your pt.
AEB=s/s/defining char.(this is the see, hear and feel and guess what, there goes your interventions, you have to perform it anyway. Hope this helps someone
Risk for injury r/t impaired mobility (this could be used for practically every PCS)
outcome: The pt will: remain injury free
N1: call bell within reach
N2: SR up x2
*Impaired physical mobility r/t tissue trauma AEB needing assistance with ambulation
*care planning wording:
everything I've heard is that Excelsior does not want during PCS used as a time frame. A generic "after ______ measures are completed" as well (not a failing point, just not needed)
Outcome: Pt will have clear breath sounds after respiratory hygiene completed.
Outcome: Pt. will not experience skin breakdown after preventive measures completed
Quote from Dr. A:
The measureable part of the statement is the actual patient outcome. It is possible to measure the statement '...will remain free from injury' because it is either accomplished by no injury occuring or not accomplished because the patient sustained an injury. Simply stated an outcome is measureable if you can determine if it was met or not met. Including during the PCS or hospital stay does not make a patient outcome measureable, all that statement does is specify when you want to see the outcome achieved.
Patient outcomes don't have to be limited to being accomplished during your PCS. The outcome should be one that is reachable by the pateint whether it is during your PCS or the patient's hospital stay.
*be sure to declare pain level when doing vitals if assigned.
*ID YOUR PATIENT FROM THE MAR AND BRACELET IMMEDIATELY BEFORE ADMINISTERING ANY DRUG OR PERFORMING WOUND CARE.
*acceptable levels of pain
0-10 scale 3/10
Flaac scale 2/10
Face scale 2/10
-Vital sign limits for med admin will be given on kardex except for Digoxin
-reps for ROM exercises: Fundamental text says 3-5, SG says only 1 time
-need to gel after I touch my pen: answer is no
-What is acceptable difference on b/p? 6 on each diasystolic and systolic.
-palpate brachial artery for b/p
-b/p document first sound systolic and last sound is diasystolic.
-Patient need to void before ABD assessment is recommended
-Bowel sounds: listen until you are hear sounds, not necessary to listen for X amount of time.
-If we are assigned application of cold for musculoskeletal management it can also count for comfort management
-If the RN administered pain medication at our request does it count for comfort management, NO, you have to be the one doing it. Yes, for pain management
-able to highlight kardex, except for Friday night
Remember to document:
Mobility status - how mobile are they?
Any balance abnormalities?
Any assistive devices? (Side rails, you, a walker, cain, etc)
You will be assigned to either ambulate, turn, or position your pt in every PCS.
M: mobility level
A: abnormalities (atrophy)
D: devices needed
O: off load
*must do one intervention: A, T, O, P. Look at Kardex for assignment
Selected Areas of Care:
*All 4 quadrants. CHART all 4 quadrant. Not “bowel sounds.” “Bowel sounds present all 4 quadrants.”
P: postion (HOB flat, knees flexed)
L: look (inspects for distention)
L: Listen (auscultates bowel sounds in all 4 quadrants)
F: feel (light palpation, 4quads for tenderness/rigidity)
S: suction off/on?
Documention: Abdomen soft and non-distended, presence of bowel sounds in a 4 quadrants. Upon light palpation in all 4 quadrants, no tenderness or rigidity.
L: LOC (time, place, name)
A: anterior font in infant
M: movement (hand squeeze/plantar flexion simultaneously)
P: PERRL (pupils, equal, round, and reactive to light)
Documentation: Alert and oriented to person, place and time. Pupils equal and reactive to light. Hand grasps and plantar flexion against resistance strong bilaterally and equal. Verbalization clear and understandable.
*inspect and palpate skin
*skin areas: heels, coccygeal/sacral, peri anal, occiput, trochanter
C color changes
I integrity (no rash, pressure effects)
E edema (present or absent)
M moisture (perspiration)
Documentation: Both heels non-reddened, warm to touch and skin is dry and intact. No edema noted. Skin over coccyx is warm, intact with redness noted. No edema. Moisture visible in skins folds of buttocks. Pt positioned to right side with pillow supporting the back.
*you can assess pulses separately, but simultaneously is preferred
*verbalize: your hands/feet feel warm, cool
*a pt may be experiencing pain in a limb and also may not be able to feel stimuli.
P: pulses bilat
C: cap refill/color
Documentation: Left and right lower extremities have palpable and equal pedal pulses. Toes of both feet were wiggled simultaneously without difficulty upon command. With her eyes closed, pt states that she feels touch in multiple toes of both feet, correctly. Cap refill less then3 seconds in toes of both feet. Temperature warm to touch in toes of both feet.
nsg dx: Ineffective peripheral tissue perfusion r/t to compromised blood flow aeb pale, cool, extremities
Outcome: pt will coorperate with tx plan to imrpove circulation
N1: elevate legs
N2: perform PVA assessment of lower extremities
nsg dx: acute pain r/t to decreased tissue perfusion aeb pt states a pain level of 7 on the pain rating scale of 0-10
outcome: pt will rate pain at or less than 3 on a scale of 0-10
N1: elevate leg on one pilow at alll times
N2: reposition pt
P: position upright
L: look at breathing pattern (rhythm, depth, access muscles)
S: sp02 if ordered
Documentation: Breathing even and regular with adequate depth and rhythm with no use of accessory muscles. Breath sounds posteriorly clear bilaterally in uppper and lower lobes. Pt on room air with oxygen saturation 97% with no apparent discomfort.
*wear gloves if your pt is having a productive cough
*observe breathing patterns while the pt breathes in and out as deeply as possible
*observe for side effects of deep breathing, lightheadedness/dizziness
*after intervention (IS/CDB), reassess in the SAME position as initial assessment
*note any change in your pt's breathing pattern
L: look pattern
S: sp02 if ordered
Documentation: Breathing pattern unlabored and regular, breath sounds clear bilaterally in upper and lower lobes. Deep breathing and coughing times three without expectoration of sputum. Breath sounds remain clear bilaterally in posterior upper and lower lobes after treatment; no change in breathing pattern or chest movement. Patient tolerated activity without shortness of breath or dyspnea.
Nsg Dx: Ineffective airway clearance acceptable s/s: ineffective or absent cough, inability to move airway secretions, abnormal brath sounds, abnormal resp rhythm, rate, and depth
S: skin surfaces
O: O2 status (sp02, nail beds, supplemental 02)
A: activity response
P: position pt for breathing
Documentation (long version): Oxygen maintained a 2L via nasal cannula. Skin intact and non-reddened around areas where tubing is in contact to skin. Pt c/o nasal irratation and humidity applied to flow meter for pt comfort. Capillary refill less than 3 seconds on fingers of both hands. Pt able to ambulate to the bathroom without shortness of breath.
Documentation (easy version): Activity tol with no SOB noted; 02 saturation 94% on room air. Skin behind ears and nares intact. States he is comfortable.
Medical dx with Nsg dx:
Pneumonia: ineffective airway clearance
PVD: alt tissue perfusion
CHF: activity intolerance r/t decreased CO aeb dyspnea on exertion and fatigue
outcome: pt will be able to wash hands and face without becoming dyspneic
N1: place articles needed for ADL's within patient's reach
N2: provide frequent rest periods during ADL's
Impaired gas exchange r/t ventilation and perfusion imbalance aeb pt requiring 2L 02 per NC to maintain saturation levels greater than 92%.
Outcome: pt will have 02 saturations greater than 92%
N1: Measure 02 saturation
N2: Position pt upright
*provide 3 measures
A: assess need, ask pt to describe comfort needs
M: Mouth care/wash hands or face
B: back rub
Documentation: Pt c/o of discomfort in her lower back and says, "All I do is lie on my back all day." Back massaged with lotion, repositioned on left side after clean linens applied. Pt states she feels "mush more comfortable now."
M: mobility level
P: pain with movement
Traction: w: wht amt, A: alignment R: ropes hang freely C: contertraction
Documentation: Active ROM, right side moves easily with full range of motion to wrist, elbow, shoulder, hip, knee, and ankle joints. Passive ROM to left side. Wrist and elbow with limited movement, shoulder fixed. Flexion and extension of left ankle performed. Left hip and knee with flexion contractures. Body alignment maintained by use of pillow, repositioned x1 to right side. Pt tolerated activity with no shortness of breath or diaphoresis, but did state pain with movement in left leg and fatigue.
*telling the primary RN is one of 2 interventions
*don't confuse comfort management with pain management
*Point of clarification: You can use that as a nursing intervention, not to meet a pain/comfort measure. That is different. For example, if you use Assess pain as one intervention on your careplan, you could list Ask staff nurse to medicate patient for pain level 4 or greater. CivitaNurse FAculty
*wait for 20-30min to eval med effect and at the same time check pt's response to other measures for relief
P: pain level
A: admin pain meds or notify nurse of pain level
R: reposition/back rub
Documentation: Pt c/o of sharp right hip incision pain and rated pain level at 4 on scale of 0-10. Pt repositioned and back rub given. Pt continued to rate pain as 4 after repositioning and back rub. Level of pain reported to assigned staff nurse who medicated the pt with 2 tablets of Tylenol #3 at 0915. Thirty minutes after taking the Tylenol #3, the patient rated level of pain as 1 on a scale of 0-10.
*irrigation: 35ml syringe with 19gauge angiocath
*abnormal/normal findings: sanguinous/serosanguinous/serous/purulent drainage, reddened, edematous, wound bed pink, skin inflammed, tenderness, granulation tissue,
G: gloves on
R: remove soil dsg
A: assess: (loc/type/appearance/drainage)
C: clense wound/irrigate/topical
P: protection sterile or clean
S: secure dsg
Documentation: Left hip incision cleansed with normal saline. Wound edges are approximated, no redness, tenderness, or exudate noted. Surrounding skin intact. Dry sterile dressing applied. Pt tolerated dressing change without compliant.
*drainage collection can include: ng/gastr/intest decompression tubes, foley, ostomies
*specimens: urine, stool, sputum, wound drainage
Documentation drainage: Nasogastric tube draining via intermittent low wall suction with lg amt of bile-colored drainage. Nares care performed and no redness noted.
Documentation collection: Sterile urine culture obtained via foley catheter, labeled and sent to lab.
*I just spoke with Excelsior and they said any tube feeding is ENTERAL and goes under enteral intake and then the specifics of the feeding go under the "ENTERAL FEEDING" box in the lower left. Make sure to document the amount of flush before and after feeding in the "ENTERAL INTAKE" box.
*if assigned: must verify placement x1 during PCS with aspirating/instilling air
*record, kind oral feeding, type, strength, amt
NG tubes are not parenteral (if they are used for a feeding it is enteral) Parenteral is OUTSIDE of the enteral track. If you dont have to change the bag, there is nothing in that box. If there is a tube feed, it is usually a g tube, and goes under enteral feeding. You
document everything about mobility in the box. Civita Nurse Faculty
*carefully check the label on feedings before opening the container
*If it is an NG/G tube where placement is determined by x-ray, the CE will not expect you to verify by the air/asp method (time frame?)
*In addition, verify the location of nasogastric feeding tube at least once during the PCS
(which one is correct????)
S: solution/formula type (full or 1/2 strength)
S: start feeding
S: sol type/amt!!!
N: no contamination
P: protect surrounding skin
Documentation: Pt placed in left Sims position. Fleets retention enema, 100ml administered rectally. Pt instructed to retain as long as possible. Assisted to bathroom. Large amount of brown formed stood and enema solution evacuated by pt.
*IV med: record on PCS recording form BEFORE admin med and check IV
*ex: if giving med with 50ml IVMB over 30min, document in parenteral intake box, "50ml IVMB" and then under medication box ICD setting document: 100ml per hour
W wash hands
A apical/BP check?
R rights x5
M med to room
W wash hands
I Id pt to mar
G give med
S sign mar
R: readiness to learn
E: evaluate need "would you like more info regarding _______?"
A: accurate info provided
D: did they get it? repeat back
L: learning readiness
I: Info provided
P: pt response
Medication teaching example:
The pt stated that now is a good time to talk about taking her medications. The pt was assessed regarding her understanding of how to take her medications. I asked her to tell me how and when she used her ______. She stated she only used her _____ when _____. Asked if she felt she was controlling her ______. She answered ______. She agreeed to review the indications for use and felt read to discuss this right away. After the review the pt was able to explain when she needed to take _____ in the future and demonstrated proper administration. She said she felt better after going over the information.
Teaching topics: fluid restrictions, meds, use of heat/cold, relaxation methods, importance of completing med prescription, oxygen safety and use, balance rest and activity periods, wound care, use of mobility devices, hazards of immobility
CPNE 16th edition updates/and things to remember:
*encouraging fluids assigned on kardex: must offer fluids to pt
*20 min check: compare on Kardex:
1. IV fluids rate/type
(record on PSC form)
2. enteral feeding rate/type
*IVAD: document the flush amt on the pcs recording form
Questions for phone conference:
1. must verbalize exp date and allergies?
2. can we tap out bubbles with a pen?
3. HR and RR can we count at 15sec?
4. Must we verbalize 5 rights to CE? What are the appropiate steps in completing this?
5. Lab: if I draw to much med can I expel to proper dose? If still in vial, can we push back in if it is not mult med in syringe?
6. must cap needle to show CE in lab?
7. cont NG feeding, need to asp and check air for placement during PCS?
8. Ok steps: wash hands, intro, check ID, glove up, check iv, wash hands, and cont 20min check?
9. radial pulse: must we check both wrists to see best place to count. If we feel and it is good, can we just go with that one?
10. Pain relief: after 30min pain med given, do we have to wait to reassess other interventions (rposition/back rub/relaxation) until then?
11. Invoking CDM, where do we document this? Narrative AOC or other?
12. What narcs do you need to check resp rate? all? or just morphine?
13. Everytime we leave the room, do we physically have to check, bed in low position, bed locked, hand rails up and secure, call light within reach? Can we visualize this? Do we have to verbalize this action while we observe or physcially perform it?
14. NG is documented per x-ray, do we have to check placement during our PCS, what timeline is this acceptable. All hospitals order an x-ray after placement.
*to copy and paste this to your computer as a reference. Highlight notes, hit control 'C' to copy, and then where you want it pasted, hit control 'V'.