CPNE Critical elements

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BEFORE PCS

CAREPLAN, GRID, SUPPLIES, BASELINES, REPORT, PRAY

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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.

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VITAL SIGNS

TEMP, PULSE, RESP, BP, PAIN, *O2 Sat, *WT RECORD x2

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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

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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

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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

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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

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PERIPHERAL VASCULAR ASSESSMENT

PALPATE/COMPARE MOST DISTAL PULSES, CAP REFILL OR COLOR, TEMPERATURE, TACTILE STIMULI, MOVEMENT OF EXTREMITIES, DOCUMENT

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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

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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

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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

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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

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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

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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

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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

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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

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WOUND MANAGEMENT

ASSESS WOUND(LOCATION,TYPE,APPEARANCE,DRAINAGE), DRSG. - IRRIGATE/CLEANSE/TOPICAL PREP/DRSG ORDERED, DOCUMENT/PT RESPONSE

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PATIENT TEACHING

LEVEL OF READINESS/BARRIERS, EVALUATE KNOWLEDGE/NEED, TEACH, RE-EVALUATE UNDERSTANDING, DOCUMENT/PT. RESPONSE

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MANAGEMENT OF ACTIVITY OF CARE

ASSESS, IMPLEMENT, REASSESS

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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

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TRACTION

TRACTION WEIGHT ACCURATE, ROPES UNOBSTRUTED, CHECK PT. ALIGNMENT, CHECK COUNTERTRACTION, ENSURE WEIGHTS HANG FREELY

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SUCTION

SET PRESSURE, CHECK PATENCY OF CATHETER, INSERT CATHETER, ROTATE CATHETER WHILE SUCTIONING, SUCTION ONLY 15 SECONDS, CONTINUE AFTER 1 MINUTE UNTIL SECRETIONS GONE

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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

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IV HEPLOCKS

WASH HANDS, GLOVE, CHECK IV SITE, VERIFY FLUSH, ASPIRATE, FLUSH BEFORE/AFTER(MEDS), DOCUMENT

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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

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I/O

MEASURE, RECORD AMT./TYPE (+/- 10 MINS.)

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D/C IV

WASH HANDS, GLOVES, ASSESS IV SITE, REMOVE IV,APPLY PRESSURE, APPLY DRSG.

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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

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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

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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

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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

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Created by: chel4u84