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CPNE Documentation

CPNE Documentation-Buzz words

MOBILITY stand or reposition self, Supported with pillows, proper alignment maintained, ambulation, complaints of, gait/balance, pt response "...."
SKIN ASSESSMENT Color changes, Integrity (ex. lesions, rash, tears, etc.) Skin Temp., Edema, Moisture (perspiration, incontinence, diarrhea, non-intact ostomy/drainage system)
ABDOMINAL ASSESSMENT distention, Bowel sounds present all four quadrants, rigidity, tenderness, tolerated procedure, knees flexed, pt supine, supine with knees flat
RESPIRATORY ASSESSMENT fowlers position, Comparison of Breath sounds bilateral upper and lower lobes, Abnormal breathing patterns (Labored/Non-labored, even). No obvious accessory muscle use. O2 Sat
PERIPHERAL VASCULAR ASSESSMENT Bilateral, distal, pulses, equal, strong, pedal, Skin warm, pink, non-edematous, Moves all, dull/sharp sensations,
NEUROLOGICAL ASSESSMENT Eyes open, PERRL, grasp hands or move feet, Noxious stimuli, Patient withdraws or grimaces, Awake, alert, oriented to person, place, time, grasp and dorsi-plantar flexion strong. Wiggles all fingers and toes, bilaterally.
RESPIRATORY MANAGEMENT abnormal, upper and lower lobes, bilaterally, accessory muscle use, rate and depth, Suctioned, unchanged, improved, Posterior, coughed, fowlers, labored, even, non-labored, Instructed to deep breathe and cough x3, non-productive, incentive sp
COMFORT MANAGEMENT resting comfortably, Pain on 0-10 scale, linen change, Repositioned, "quote pt statements", mouth care, Washed hands and face
FLUID MANAGEMENT Hydration status (turgor, MM, fontanel) IV site Appearance (temp, edema)GLOVES ON IV solution infusing &verify Rate/GTTS) SAME W/ CONTIN.FEEDINGS (sol/rate)
MUSCULOSKELETAL MANAGEMENT pain, medicated, AROM exercises, PROM, Assisted with flexion/extention, abduction/adduction, tolerated,
OXYGEN MANAGEMENT Pt response to activity (SOB, dyspnea on exertion after repositioning, ambulating, or participating in activities) O2 device & rate (2l via NC) Oxygentation Status-(measure O2 Sats or CRT/nailbed color, or clubbing) Skin condition and pt response
PAIN MANAGEMENT Pain level (scale, flacc, faces) OLD CART Adm pain meds? or reported info to the RN What pain relief measure you implemented(backrub) pt pain level on reassessment (pt response)
WOUND MANAGEMENT medicated, intact blister, drainage, serous fluid, Skin red, warm, intact, Applied..ordered, Patient tol,
PATIENT TEACHING 1. pts readiness to learn (doc quest/pt resp) 2.learning needs (Ask ? to eval.prior knowledge and what they want to learn) 3. Information taught to the pt. ID barriers/KISS 4.Determine pt understanding of teaching (pt explains what he learned)""
PRIORITY CP STATEMENT ___ is a basic physiologic need. Failure to meet this need will subject the patient to a number of complications, including ____ ,____, and ____. Any of the preceding conditions would lengthen the patients hospital stay and delay the recovery process.
Created by: chel4u84