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.

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????

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.

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

Record:

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.

• read the link for a thorough guide in abdomenal assements. Examination of the Abdomen

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

Records:

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

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