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.

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

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

Pain Management p 232 17th Edition CPNE Excelsior Study Guide

ask patient to rank pain:

• Adults on scale of 0-10,  or a visual analog scale
• child of 3 or older use the faces 0-5 or visual analog
• 2 months to 3 years use the FLACC
• observing behavior indicative of pain

assess patient's pain location by asking the patient to point to the location of the pain

• if the patient is unable to verbalize or communicate location observe
• pulling on ear
• limping
• rubbing  an area

assess the quality of the pain by asking the patient the characteristics of the pain

• sharp
• dull
• stabbing
• aching
• throbbing

assess the duration of pain by asking the patient:

•  how long does the pain last
•  how often does it occur
• how long have you experienced this pain

provide three of the following pain relief measures

1. repositions the patient or assists the patient to a different position
2. gives the patient a back
3. uses relaxation and/or distraction techniques
1. guided imagery
2. watching TV
3. drawing a picture or coloring
4. engage in conversation about a happy memory or hobby
5. pacifier
6. cuddling
7. play
8. singing
4. applies heat or cold when assigned
5. administer pain med when assigned, or
6. if not assigned request the primary nurse to administer pain med

reassess the patient's pain by:

• asking the adult patient to rate the pain on a scale of 0-10 or visual analog scale
• asking the child of 3 or older to rate the pain on a 0-5 Faces scale or visual analog scale
• using the FLACC pain assessment tool to rate level of pain for a child ranging in age 2 months to 3 years of age
• observing behavior indicative of pain in an infant or noncommunicating- adult or child
• moaning,
• grimacing
• clutching
• restlessness

Records:

• level of pain
• location of pain
• intensity of pain
• duration of pain
• characteristics of pain
• predisposing factors
• aggravating factors
• measures to relieve pain
• patients response to measures to relieve pain

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

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.