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.

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.

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.

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