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CPNE#1
CPNE Critical elements
| Question | Answer |
|---|---|
| BEFORE PCS | CAREPLAN, GRID, SUPPLIES, BASELINES, REPORT, PRAY |
| 20 MINUTE CHECK | WASH HANDS, INTRO. SELF/CE, EXPLAIN, ID PATIENT, GLOVE, CHECK IV FLUID/TUBE FEEDING (TYPE, FLOW, AMT LEFT IN BAG STATE TO CE) DOCUMENT, TURGOR, REMOVE GLOVES, WASH HANDS. |
| VITAL SIGNS | TEMP, PULSE, RESP, BP, PAIN, *O2 Sat, *WT RECORD x2 |
| MOBILITY | BATHROBE/BARRIER, SLIPPERS, LEVEL OF MOBILITY, ASSISTED DEVICES, SUPPORT (WEAK/INJURED AREAS), BALANCE ABNORMALITIES, AMBULATE/REPOSITION X1, KEEP SAFE, NO PRESSURE/VULNERABLE SKIN AREA DOCUMENT/PT RESPONSE |
| SKIN ASSESSMENT | ASSESS 2 AREAS (TROCHANTER, OCCIPUT, SACRAL/COCCYX, HEELS, ELBOWS, PERI-ANAL), COLOR, INTEGRITY, TEMPERATURE, EDEMA, MOISTURE (PERSPIRATION, INCONTINENCE, DIARRHEA, NON-INTACT OSTOMY/DRAINAGE SYSTEM), DOCUMENT |
| ABDOMINAL ASSESSMENT | (4 P's)PRIVACY, PEE, PAIN, POSITION (FLAT/BENT KNEES),SUCTION OFF, OBSERVE ABDOMEN, AUSCULTATE FOR BS X 4 QUADS, PALPATE FOR TENDERNESS/RIGIDITY,, SUCTION ON, MEASURE GIRTH (IF ORDERED), DOCUMENT/PT RESPONSE |
| RESPIRATORY ASSESSMENT | 4 P's (PRIVACY, PAIN, PEE, FOWLERS POSITION, OBSERVE BREATHING PATTERN, LISTEN (UPPER x2 THEN LOWER x2), MEASURE O2 SAT (WHEN ASSIGNED), DOCUMENT - COMPARE BILATERALLY (CLEAR OR ABNORMAL)/PT RESPONSE |
| PERIPHERAL VASCULAR ASSESSMENT | PALPATE/COMPARE MOST DISTAL PULSES, CAP REFILL OR COLOR, TEMPERATURE, TACTILE STIMULI, MOVEMENT OF EXTREMITIES, DOCUMENT |
| NEUROLOGICAL ASSESSMENT | LOC ORIENT X 3, PERRL, MOTOR FUNCTION - SQUEEZE HANDS & DORSI/PLANTAR FLEXION. CHILDREN - FAMILIAR FAMILY/OBJECTS, CHECK FONTANEL <1YR OF AGE, NOTE SYMMETRY & MOVEMENT. NON-RESPONISIVE PT. NOXIOUS STIMULI DOCUMENT/PT RESPONSE |
| RESPIRATORY MANAGEMENT | POSITION UPRIGHT, BASIN/TISSUES, ASSESS BEFORE TREATMENT, PROVIDE THERAPY (IS, COUGH, DEEP BREATHING, CHEST PERCUSSION) SUCTION (IF ORDERED) ASSESS, DOCUMENT (MUST DOCUMENT COMPARSION OF LUNGS BEFORE AND AFTER TREATMENT)/PT RESPONSE |
| COMFORT MANAGEMENT | ASSESS PAIN, OBSERVE BEHAVIORS OF DISCOMFORT, PROVIDE 3 (YOU GIVE MEDICATION, MOUTH CARE(GLOVES), COLD/HEAT, WASH FACE/HANDS, REPOSITION, LINEN CHG, BACK RUB(GLOVES), RELAXATION/DISTRACTION TECH., RE-ASSESS, DOCUMENT/PT RESPONSE |
| FLUID MANAGEMENT | SKIN TURGOR/MUCOUS MEMBRANES, FONTANEL <1 YR, VERIFY IVF TYPE/FLOW RATE, IV SITE CHECK, CHECK TUBE FEEDING, I&O (WATCH RESTRICT/ENCOURAGE FLUIDS), DOCUMENT |
| MUSCULOSKELETAL MANAGEMENT | MOBILITY LEVEL, ABNORMALITIES, PAIN W/MOVEMENT, AROM/PROM - DIRECT PT MOVEMENT(ABDUCTION/ADDUCTION OR FLEXION/EXTENSION, SUPPORTIVE DEVICES, HEAT/COLD, MAINTAIN TRACTION, DOCUMENT/PT RESPONSE |
| OXYGEN MANAGEMENT | ASSES BREATHING PATTERN, CHECK NAILBEDS FOR COLOR, CAP REFILL OR CLUBBING OR MEASURE O2 SAT, ASSES SKIN IN CONTACT WITH CANNULA, POSITION PT, MAINTAIN 02/HUMIDIFICATION, DOCUMENT/PT RESPONSE |
| PAIN MANAGEMENT | LEVEL OF PAIN, GIVE MEDS/ASK RN AND PAIN RELIEF MEASURES X1 (REPOSITION, BACK RUB, RELAX/DISTRACT, HEAT/COLD), REASSESS, DOCUMENT/PT RESPONSE |
| SAFETY EXIT | SIDE RAILS UP, CALL LIGHT, BED LOW POSITION, BEDSIDE TABLE, WATER, PHONE, GLASSES/DENTURES/ HEARING AIDS, TOTAL I/O'S, CHK IV RATE, WASH HANDS |
| WOUND MANAGEMENT | ASSESS WOUND(LOCATION,TYPE,APPEARANCE,DRAINAGE), DRSG. - IRRIGATE/CLEANSE/TOPICAL PREP/DRSG ORDERED, DOCUMENT/PT RESPONSE |
| PATIENT TEACHING | LEVEL OF READINESS/BARRIERS, EVALUATE KNOWLEDGE/NEED, TEACH, RE-EVALUATE UNDERSTANDING, DOCUMENT/PT. RESPONSE |
| MANAGEMENT OF ACTIVITY OF CARE | ASSESS, IMPLEMENT, REASSESS |
| MEDICATION ADMINISTRATION | WASH HANDS, GET MEDS/FLUSHES FROM MAR, WASH HANDS, CHECK PT ID TO MAR, ALLERGIES, ASSESS IV SITE (GLOVES NEEDED), ADMINISTER MEDS WITHIN +/- 30 MINUTES SCHEDULED TIME, DOCUMENT ON MAR |
| TRACTION | TRACTION WEIGHT ACCURATE, ROPES UNOBSTRUTED, CHECK PT. ALIGNMENT, CHECK COUNTERTRACTION, ENSURE WEIGHTS HANG FREELY |
| SUCTION | SET PRESSURE, CHECK PATENCY OF CATHETER, INSERT CATHETER, ROTATE CATHETER WHILE SUCTIONING, SUCTION ONLY 15 SECONDS, CONTINUE AFTER 1 MINUTE UNTIL SECRETIONS GONE |
| IV MINI BAG | VERIFY MED/MAR, ID PT W/MAR, CALCULATE GTT/RATE & RECORD, CLAMP SECONDARY LINE, HANG BAG, LOWER PRIMARY BAG, GLOVE, CHECK IV SITE, VERIFY GTT/MIN (+/- 5 GTTS), BUBBLES OUT, FINAL CHECK, GLOVES OFF, WASH HANDS, SIGN MAR |
| IV HEPLOCKS | WASH HANDS, GLOVE, CHECK IV SITE, VERIFY FLUSH, ASPIRATE, FLUSH BEFORE/AFTER(MEDS), DOCUMENT |
| IV FLUID CHANGE | VERIFY PT ID, CLEAR LINE OF AIR, HANG PROPER FLUID, GTTS/MIN. OR RATE, WASH HANDS, GLOVES, CHECK IV SITE GLOVES OFF, DOCUMENT |
| I/O | MEASURE, RECORD AMT./TYPE (+/- 10 MINS.) |
| D/C IV | WASH HANDS, GLOVES, ASSESS IV SITE, REMOVE IV,APPLY PRESSURE, APPLY DRSG. |
| DRAINAGE/SPECIMEN COLLECTION | ASSESS AMT & COLOR OF DRAINAGE, CLEAN SURROUNDING SKIN, INSERT TUBE, DRAINAGE BY TUBE - MAINTAIN/ ATTACHES TUBE, MAINTAINS PATENCY, MAINTAINS GRAVITY/ SUCTION, SPECIMEN COLLECTION - CONTAINER, LABEL, SPECIMEN, SEND TO LAB, DOCUMENT |
| ENTERAL FEEDINGS | TIME +/- 30 MINS.,UPRIGHT POSITION,BURP CHILD <6 MONTHS,ENSURE PROPER FEEDING & DEVICE,PLACEMENT CHECK(ASPIRATION RESIDUAL - MEASURE & RETURN/AUSCULATION, ACCURACY OF FLOW(GTT/MIN), TEMP. OF FEEDING, DOCUMENT |
| IRRIGATION | POSITION PT., VERIFY TUBE PLACEMENT, CHECK FLUID TEMPERATURE, RECEPTACLE, KEEP PT. DRY, GOOD RETURN FLOW, DOCUMENT - TYPE/AMOUNT OF FLUID, DESCRIBE DRAINAGE, PT. TOLERANCE |
| VITAL SIGNS | ORAL TEMP - GLOVES , +/- 20 MINUTES PULSE - COUNT FULL MINUTE, RADIAL (IF IRREGULAR TAKE APICAL B/P - PALPATE BRACHIAL PULSE, INFLATE 25MM/HG ABOVE ABOVE BASELINE SBP WT- 0 SCALE, BARRIER, SLIPPERS, CLEAN AFTER USE |
Created by:
chel4u84