david's cpne critical elements

CPNE Critical elements in pla... http://docs.google.com/View?docid=dd3vnpzc_96hdqdqs

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CPNE Critical elements in plain english

#1

1. Write a Care Plan that has two problem labels that comes from the list of overriding, required and

selected areas of care that are marked on your Assignment card. One of them has to be a real problem

and not a risk for problem.

List an outcome that you can measure for each problem or diagnosis.

List 2 things that you will do to try and help the patient reach the outcome you wrote down. So there

should be 4 things you do total and they should be things you can do during the PCS.

2. Write down the flow rate in drops per minute on the Care plan if there is a gravity flow IV in the

patient. Make sure that you write down the right flow rate!

#2

Clinical Decision Making

CDM means that your try to solve problems by making choices during your patient care. It means using

good judgement and you knowledge of Nursing and keeping the patients best interest in mind.

If your going to not do or change a critical element, you have to tell the CE what your doing and why at

the time your doing it. Don't wait to tell the CE. If the CE decides that you are not using good

judgement in problem solving, you'll fail.

OVERRIDING AREAS OF CARE

#3

Asepsis

1. Wash your hands in front of the CE before you start taking care of the patient.

2. Protect yourself, others, and the rooms your in from contamination

3. Protect the patient for contamination

4. Make a sterile area when you need to

#4

Caring

1. Don't ignore your patient. Be real and introduce yourself to the patient. Treat your patient the way

you want to be treated.

After the introduction ID the patient by checking at least 2 of these:

1) the patients name

2) when the patient was born

3) the patients Medical record number

Then explain what your doing there. If your patient is a child or adult that doesn't talk use touch if it's

OK culturally. Figure that out by asking relatives of the assigned nurse if your don't know whats OK


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culturally. Don't ignore your patient or act as if they don't matter just because they don't talk.

#5

Caring Cont.

2. Talk to your patient and their significant others in a way that they can understand.

Also encourage the patient to let you know what they need.

Respond when your patient talks to you.

Respond to the patients body language, for example when your patients winces in pain, ask about it.

To help when your taking care of the patient

explain what your about to do

ask about how your patient feels about the care your giving

ask if your patient is comfortable

talk about things that are important to your patient

ask your patient what order they would want they're care tasks done in

3. Don't be patronizing, demeaning or rag on your patient in any way, verbally or physically. If you

treat people bad, nursing is not for you.

4. Be respectful, treat your patient with dignity and respect their culture.

#6

Emotional Jeopardy

Anything you do or don't do that threatens your patients or their friends and relatives emotional well

being will end the PCS and you'll fail.

#7

Mobility

1. Check the patient

for the way they get around or can't get around

the way they use canes, walkers or other things they use to get around

if they have balance problems

2. Move your patient or change their position by

supporting weak or injured parts of their body

support your patients head, shoulders, and pelvis

turning, lifting, or moving your patient to a different position

use your patients body parts or helpful devices to keep your patient in the position you want them in

use positioning and/or helpful devices to reduce pressure on sensitive skin areas

do what you have to to prevent cutting your patients skin

#8

Mobility cont.

3. Help your patient move or walk by

steadying equipment

do what you have to to in order to help your patient keep their balance


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4. Write down

your patients ability to move and get around

what things your patient uses to help get around

any problems your patient has with balance

If you positioned, transferred, or walked your patient during the PCS

How your patient reacted to the positioning, transferring and/or walking.

#9

Physical Jeopardy

Anything you do or don't do that threatens your patients physical well being. Your responsible for your

patients physical safety for the entire PCS. If you don't report a deterioration in your patients condition

or are about to do something that might hurt your patient, the PCS will be stopped and you'll fail.

REQUIRED AREAS OF CARE

#10

Fluid Management

1. Check the fluid status of your patient in one of these ways

check the skin turgor(elasticity)

look at the inside of your patients mouth

feel the anterior fontanel(top of the head in the front. the soft spot) of a child less than 1 year old

2. for intestinal feedings by mouth or tube

determine the kind of fluid your patient is going to take in

Give or restrict fluids as ordered

3. for fluids given by IV

It's important that you do the following in the first 20 minutes of beginning your patients care

Check that the flow rate is correct by

counting the drops per minute that are flowing right now or

write down the flow rate of the pump that's running is set at the exact number for the right amount

of fluid to be delivered. Make sure you write on the PCS form.

#11

Fluid Management cont.

Check the area where the line goes into your patient. It might be a central, on arms or legs, or

implanted in the vein type of device. Look for problems such as dislocation, infiltration(fluid going into

the tissue instead of the vein) or other problems by

feeling the skin around the IV for changes in temperature. It might be cooler or warming than the

rest of the surrounding skin

or feeling the area for edema

If the flow rate is not right change it by

adjusting the flow to plus or minus 5 drops per minute of the rate you calculated. It's the same

for microdrops.

if it's on a pump, adjust the pump to the exact number required to deliver the prescribed volume

Write the prescribed fluid that's going into your patient on the PCS form


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#12


For the entire implementation period:

Give the fluids prescribed

Gives the prescribed amount of fluid per hour while staying within the following error range

Plus or Minus 25 ml per hour if the patient is over 2 years old

Plus or minus 10 ml per hour if the patient is under 2 years old

Recalculate the flow rate or change the ICD setting if the Doctors order changes

#13


4. When the next ordered primary IV fluid is needed

pick the right fluid

figure out the amount of fluid to infuse for the correct amount of time

ID your patient immediately before you set up the IV solution by checking at least 2 pieces of

patient information

your patients name

your patients birth date

your patients medical record number

Check the IV site for problems such as infiltration, or the device having pulled out. Check by either

Feeling the skin around the site for coolness or warmth

Feel the skin around the site for swelling/edema

#14


Make sure the flow rate is right by adjusting the drip rate to within plus or minus 5 drops a minute

of the rate you calculated.

Or if a pump is used make sure that it's set to the exact number so that it will give the correct

volume

Don't forget to write the fluid being given on the PCS form

When you have to maintain an intermittent access device like a hep lock

check the insertion site for infiltration or other problems by

feeling the skin around the site for warmth or coolness or

feeling the area for swelling/edema

Aspirate for blood unless there's a good reason not to. It's very important to aspirate because that

tells you the line is in a vein

Flush the hep lock or similar device with the correct fluid

Don't forget to chart the flush solution on the PCS form

#15


When the IV in an extremity is discontinued you will


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check the condition of the IV site

remove the cannula

put pressure on the IV injection site

put a covering or bandage on the site

4. When the patient is getting IV nutrition or tube feeding you will

measure the amount of fluid taken in

make sure that your measurement is within plus or minus 10 percent of the actual amount taken in

don't forget to chart the kind of fluid your patient took in

remember to chart hourly intake on the PCS form within 10 minutes of the ordered time when

hourly intake is assigned to you

#16


5. When your assigned to output you must

collect the output

measure it for the entire time your taking care of the patient

record the right amount on the PCS form. Your allowed a 10 percent error. ( output from catheters

or other drainage is not measured unless your told to.)

you must also record the hourly output when that's assigned. make sure to record within 10 minutes

of the designated time.

6. Chart your patients Hydration status and the condition of the IV site

#17

Vital Signs

Get accurate vital signs by reading the thermometer within plus or minus 2 tenths of a degree.

Measure the pulse by counting within plus or minus 5 beats a minute. Your allowed a 10 beats a

minute error for a patient under 2 years old

Count the breaths within 2 breaths of actual. Your allowed a 6 breath error for a child under 2

Read the blood pressure device within 6 millimeters of mercury

#18

Vital Signs

Make sure you get an accurate weight when it's assigned to you by

balancing the scale

undress the patient if needed

keep the scale clean

your only allowed a 1% error on weights

Don't forget to get the O2 saturation when your assigned

Check your patients level of pain when pain is assigned to you by

asking your adult patient that talks to rate their pain on a 1 to 10 scale

ask your talking child patient to rate their pain on a 1 to 5 faces scale

If your patient doesn't talk watch them for behaviors like moaning, grimacing or restlessness

3. Chart every one of the assigned vital signs on the PCS form


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SELECTED AREAS OF CARE

#19

Abdominal Assessment

1. Put your patient in the best position for the assessment

2. Look at the abdomen for distention

3. Listen for bowel sounds in all four quadrants. You might have to listen for as long as 5 minutes to be

sure there are no bowel sounds

4. Lightly touch all four quadrants, checking for tenderness or rigidity. Unless there's a problem that

would prevent it

5. If your assigned to measure the girth of the abdomen

7. Chart all of your findings. If your patient is distended, whether or not there are bowel sounds in each

quadrant, If there is any tenderness or rigidity and the girth of the abdomen if you were assigned that.

#20

Neurological assessment

1. Check your patients level of consciousness by

asking if they know the time, where they are, who they are or

see if they can recognize people they should be familiar with or know the names of common objects

in the room.

If your patient is a child between 1 and 3 or an adult that doesn't talk show then things, make

sounds, or hand them things to touch.

2. Feel the anterior fontanel if your patient is a child under one year of age. Make sure the child is

upright, unless there's a problem that would prevent it. If the child is lying down the fontanel might

bulge normally.

#21

Neurological assessment cont

4. Check your patients pupils to see if they are both the same size and if they react to light.

5. Check the motor response of your patient in the arms and legs by

asking them to squeeze the fingers of both your hands with their hands and then to push against

your hands with both feet, either up or down

If your patient can't do those things watch their musculoskeletal responses for evenness on both

sides and movement

6. Check the patients response to pain, for example pressing the nailbeds. Do this only if they don't

respond when you talk to them.

#22

Neurological assessment cont


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7. Make sure that you chart everything you observed like the patients

level of consciousness

the condition of the fontanel

how the pupils of their eyes responded

Weather the motor response on both sides were the same

If they reacted to pain

#23

Peripheral Vascular Assessment

1 Compare your patients arms and legs by

feeling for the pulses that are most distal

compare those distal pulses with the ones on the other extremity. Compare right and left ankle

pulses

check blood supply of the arms and legs

checking capillary refill or looking at the color of the fingers and toes

check the temperature of the fingers, toes, hands, feet, arms and legs

see if the patient can feel it when you touch their toes and fingers. Have them look away or close

their eyes

#24

Peripheral Vascular Assessment cont

check motor function by

asking your patient to move their arms and legs, fingers and toes

watch and note the movement of the arms and legs of a child under 3 or an adult that doesn't talk

3. Chart want you observed, especially the differences between left and right sides

were there distal pulses?

How long did it take for capillaries to refill and what was the color?

where the fingers and toes cool or warm?

Did you patient notice touch?

Were they able to move OK?

#25

Respiratory Assessment

1. Put your patient in a position to help your assessment

2. Check your patients breathing by

Tell your patient to breathe in and out as deeply as possible

Listen to your patients breath sounds in the upper and lower lobes moving the stethoscope from side

to side

Check your patients breathing patterns

When it's assigned to you check your patients O2 saturation

#26


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Respiratory Assessment cont.

Don't forget to chart your observations related to

How the breath sounds on both sides compared

Any abnormal breathing patterns

O2 saturation if you were assigned to it

#27

Comfort Management

1. Assess what your patient needs to increase their comfort by

Ask your patient what they want to feel more comfortable

Look for behaviors from your patient that indicate they are uncomfortable

2. Do 3 of the things on this list

1) Help your patient wash their face, hands, and/of skin that's at risk for breakdown

2) Help your patient into a more comfortable position

3) Give your patient a backrub

4) Teach them relaxation or distraction methods

5) Apply heat or Cold if it was assigned to you

6) Help your patient with mouth care

7) Change or adjust your patients bed linens

8) Give your patient the medications that you were assigned to

#28

Comfort Management cont

Chart

What you observed about your patients comfort needs or discomfort

What you did to make your patient more comfortable

How your patient responded to the things you did

#29

Musculoskeletal Management

1. Check the area of your patients designated extremity(ies) for

Is there anything abnormal like atrophy?

How mobile is your patient?

Does it hurt your patient to move?

2 Tell your patient to move the designated arm or leg including at least one pair of abduction and

adduction, flexion and extension

3.Move your patients extremities through at least one pair of abduction and adduction, flexion and


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extension

Support your patients arm or leg weight while your moving them

#30

Musculoskeletal Management cont

5. Apply heat or cold to your patient if it was assigned to you by

a. Protect the skin of the area that will be treated

b. Apply the treatment (heat or cold)

c. make sure you get the temperature of the treatment right

d. treat for at least 20 minutes unless you've been told otherwise

6. If your patient has traction you should

a. check the amount of weight ordered

b. Make sure nothing is in the way of the ropes

c. See that the weights hang freely

d. Keep your patient in a position to provide counteraction to the traction

e. Keep your patient in correct alignment

7. Charting

what you observed related to the abnormalities in the arms and legs

how well your patient can move the designated arms and legs

Does your patient have pain moving the designated arms or legs?

What things you did for your patient and how your patient responded

#31

Oxygen Management

1. Check how your patient responds to activity

2. Check their Oxygen status by

a. Checking the nailbeds for color, capillary refill, clubbing

b. Measure the O2 saturation when assigned

3. Check the skin surfaces that touch the O2 delivery system like the nasal cannula

4. Put your patient in a position that makes it easier to breathe

5. Make sure you set, adjust and maintain the O2 flow at the right rate

6. If there's humidification make sure you maintain it

#32

Oxygen Management cont

7. Keep the room from exploding or burning by removing things that can spark

8. Apply and maintain your patients oxygen delivery system at the right rate of delivery

9. Apply and maintain instruments that measure O2 saturation level when it's assigned

10. Chart

1) Your patients response to activity

2) O2 status

3) Condition of the skin that's in touch with O2 tubing

What you did to manage your patients Oxygen status


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Your patients response to what you did

#33

Pain Management

1. Determine your patients pain level by

asking them to rate pain on a 1 to 10 scale or visual analog scale or

if your patient is a child to rate pain on a 1 to 5 faces scale or

watch for things like moaning, grimacing, clutching or restlessness if your patient can't rate their

pain

2. Give pain medication if medications were assigned to you

3. Tell the assigned staff nurse your patients pain level

#34

Pain Management cont

4. Do one of the following things to provide pain relief

move your patient to a more comfortable position

give your patient a backrub

teach your patient relaxation and distraction techniques

apply heat or cold if it was assigned to you

5. Check your patient again with all the same methods

ask them to rate on a 1 to 10 scale

use the 1 to 5 faces scale for a child

observe for behaviors that indicate pain

6. Chart

Your patients pain level

What you did to relieve their pain

what was your patients response to what you did

#35

Respiratory Management

1. Put your patient in a position to make the respiratory hygiene activities easier

2. Give your patient a receptacle to spit in

3. Check your patients breathing before starting the respiratory hygiene activities by

a. Tell your patient to breathe in and out as deeply as possible

b. listen to your patients breath sounds over the upper and lower lobes. Move the stethoscope from

side to side (4 lobes)

c. Watch their breathing patterns

#36

Respiratory Management cont


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5. Help you patient with or preform one or more respiratory hygiene activities

a deep breathing

1) Instruct your patient to breathe in and out as deeply as possible

2) Repeat deep breathing exercise as ordered or needed by the patient

b coughing

1) Tell your patient to breathe in and out as deeply as possible

2) have your patient cough forcefully on the third or forth exhalation

3) Help with splinting if needed (Splint your incision before you cough. Place one hand above and one below you incision. Splinting is

important and remember to do it.)

c Use of mechanical devices such as incentive spirometer

1) teach your patient how to use the device

2) Have your patient repeat the exercise as ordered or as tolerated

#37


d. Chest percussion

1) Clap vigorously on your patients chest wall in the area designated unless contraindicated

2) Vibrate vigorously on your patients chest wall unless contraindicated

e. Suctioning:

1) If your assigned to suction by catheter:

a. Make sure the catheter is clear

b. Set the right pressure on the machine

c. Insert the catheter before turning on the machine

d. Keep rotating the catheter while suctioning

e. DO NOT SUCTION FOR MORE THAN 15 seconds at a time

f. repeat suctioning as needed to remove your patients secretions

#38


2) If your assigned to bulb syringe suctioning:

a. Deflate/squeeze the bulb syringe before you insert it

b. Insert the bulb into your patients mouth or nostril before suctioning

c. Suction the secretions

d. repeat as necessary

6. Check you patients breathing right after the hygiene activities

7. Chart

a. the comparison of breath sounds heard before and after the treatments

b. any abnormal breathing patterns observed

c. What activities you implemented

d. What was your patients response to the activities

#39

Skin Assessment


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1. Check the skin surface of your patient for

a. color

b. Is the skin intact?

c. What is the temperature of the skin?

d. Is there an edema?

e. Is the skin dry or wet?

2. Chart your observations

a. color

b. integrity

c. temperature

d. edema

e. moisture

3. Do a pressure ulcer risk assessment using the tool provided

#40

Skin Assessment cont

4. Record the scores for each subscale and a total score within a range of plus or minus 3

5. Chart the amount of risk your patient is in for developing a pressure ulcer

#41

Wound Management

1. Check the wound, it's location, type of wound, appearance, and if there is any drainage

2. If your assigned to irrigate the wound you will

a. Select the designated solution

b. make sure it's at the right temperature

c. use the right irrigation delivery system

d. put the receptacle in the right place for the return flow

e. irrigate the wound without contaminating it

f. protect the skin around the wound from the drainage fluid

3. Clean the wound with the designated solution

4. Apply the topical that's ordered

#42

Wound Management cont

5. When you have to protect the wound you will

a. remove the dressing without contaminating the wound

b. remove the dressing without injuring the surrounding skin

c. dump the soiled dressing in the correct container

d. put the dressing on without contaminating the wound


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e. secure the dressing. Tape it down

f. Don't forget to put the date, time, and your initials on the dressing

6. remember to chart

a. what you observed about the wound.

1) it's location

2) the type of wound

3) it's appearance

4) if there was any drainage

b. What you did to clean, irrigate, and protect the wound and it's surrounding skin

c. How your patient responded to what you did

#43

Drainage and Specimen Collection

1. When your assigned to collect drainage you will

a. observe the amount and color of the drainage

b. clean the surrounding skin when your assigned to

c. put the drainage tube into the proper body cavity

d. When a tube is used for drainage

1) attach the tube to the container

2) keep the tube clear

3) maintain the drainage by gravity or suction machine

e. remove the tube if your assigned to

#44

Drainage and Specimen Collection cont

2. When your assigned to collect a specimen you will

a. get the designated specimen (Duh)

b. put the specimen in the right container and on the right surface

c. make sure the specimen is labeled

d. put the specimen in the right place for transport to the lab

3. Chart your observation about the amount and color of the specimen

4. Chart anything else related to the specimen collection

5. Document and report what happened to the specimen

#45

Enteral Feeding

1. For ALL feedings you will

a. you will choose the correct feeding

b. put your patient in the best position for feeding

c. give the feeding

2. When your assigned to assist with feeding you will


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a. pick the right feeding device

b. burp an infant under 6 months old periodically as needed

3. Give the feeding at room temperature unless your told otherwise

#46

Enteral Feeding cont

4. When your patient has an intermittent tube feeding you will

a. figure out the amount of feeding you'll give

b. calculate the drops per minute

c. Make sure the NG tube is in the stomach by one of the following ways, unless contraindicated

1) suck up stomach contents or

2) push in 10-20 ml of air while listening with a stethoscope (use 5 ml of air if your patient is less

than 2 years old)

d. Measure whats in your patients stomach before you give the feeding

e. Put back what you measured unless it's contraindicated

f. Start the feeding within 30 minutes of the prescribed time

g. Set the rate so that the feeding will be given in the specified time by either

1) adjusting the flow to within 5 drops per minute of the calculated drops

2) adjust the flow rate on the feeding pump to the exact number required

#47


5. When you have a patient with continuous tube feeding assigned you will

a. Do the following within 20 minutes of starting care for you patient

1) See that the flow rate is accurate by either

a) counting the drops per minute that are flowing or

b) charting the flow rate setting on the feeding pump in the PCS form

2) Fix the flow rate when needed by either

a) adjusting the flow to within 5 drops per minute of the calculated flow or

b) adjusting the flow rate of the feeding pump to the exact number prescribed

#48


b. make sure the NG tube is in the stomach at least once during the PCS by one of the following

methods,

1) Suck up some stomach contents or

2) Push in 10-20 ml of air while listening with a stethoscope (use 5 ml of air if your patient is less

than 2 years old)

c. When your assigned to measure whats left in the stomach you will

1) measure the stomach contents

2) Put the contents back unless contraindicated

3) figure out the amount of feeding to give

6. Chart the kind of feeding you gave


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7. Chart the name and strength of the feeding product

8. Chart the amount of feeding given

#49

Irrigation

1. Pick the designated solution

2. Make sure the solution is at the appropriate temperature

3. Make sure your patient is in the best position to help the irrigation

4. check that the tube is in the right place

5. Put the solution in the designated area

6. Control the flow rate of the solution

7. put the receptacle in the right place for return flow

8. write down the kind of irrigating solution you used

9. write down the amount of solution you used

#50

Medications

1. Use the MAR to select the prescribed medication

2. measure the prescribed dosage

3. ID you patient immediately before you give the med by verifying 2 of the following pieces of

information

a. Your patients name

b. Your patients date of birth

c. Your patients medical record number

4. Use the correct needle size for the injection

5. Use the prescribed route and/or site for administering medications

6. Give the prescribed meds to the right patient

7. Give the prescribed medications within 30 minutes of the scheduled time

8. When your assigned to give IV medications you will

a. Record the correct flow rate in drops per minute for gravity flow or in millimeters per hour for an

ICD on the PCS form before giving the medication

#51

Medications cont

b. Check the insertion site for dislocation, infiltration, or other complications IMMEDIATELY before

giving the medication by using one of the following methods

1) Feeling the surrounding skin for changes in temperature or

2) touching the surrounding skin for edema

c. Clear the air from the IV tubing starting the flow

d. When you patient has a Hep lock you must

1) ASPIRATE for blood return unless it's contraindicated

2) Flush the line with the designated solution BEFORE giving the medication

3) Flush the line with the designated solution AFTER giving the medication

4) Chart the flush solution used on the PCS form

e. Regulate the flow to give the prescribed amount in the correct period of time


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9. Record the medication given on the HOSPITAL MAR within 30 minutes of the time you gave it

#52

Patient Teaching

1. Determine if your patient is ready to learn by

a. assess your patients desire and ability to learn

b. See if your patient has any barriers to learning

2. Ask your patient questions to identify their learning needs

3. Give your patient accurate information thats also appropriate and consistant with identified need

4. Check you patients understanding of what you've presented by asking questions

5. Record

a. Your patients readiness to learn

b. What information you provided

c. Your patients response to the information given

#53

Evaluation of the Nursing Care Plan

david's cpne critical elements

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