help with studies for the dreaded CPNE
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Respiratory Management | Ineffective airway clearance
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| Musculoskeletal management | Impaired physical mobility
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| Comfort management | Readiness for enhanced comfort
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| Oxygen management | Activity intolerance
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| Pain management | Acute pain
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| Planning phase | 2 nursing dx with outcome and interventions. calculate gravity iv. write down meds to be given se uses teaching points labs h&h pt inr ptt dig na bun last pain med vs adl's
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| 20 min check | wash hands in sight of CE introduce self/CE check iv site-gloves check iv rate/verify solution w/ kardex & amt available verify ngt placement x2 document rate/solution of iv/enteral solution
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| Caring | I CARE
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| Fluid management | Have I drank something-Hids
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| VS | T P R BP WT O2SAT PAIN
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| Asepsis | WASH
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| Physical jeopardy-safety | SCAB
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| Emotional Jeopardy | REALITY
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| Abdominal assessment | 3P's then look listen feel
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| Neurological assessment | LAMP
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| Peripheral Vascular assessment | PTS M CC- post traumatic stress move cc
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| Respiratory assessment | PAIR
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| Skin Assessment | TIME CC
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| Mobility | MAD ATOP
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| Comfort management | COMFORTERS 3
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| Musculoskeletal management | MAP HATR
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| Oxygen management | SOAP
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| Pain management | PAIN
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| Respiratory management | HAIR must do assessment first (PAIR)
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| Wound management | WOUND
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| Medication | WATCH MARS
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| Drain/Specimen | I SPECIAL
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| Enteral Feeding | RAT FEVER
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| Irrigation | IRRIGAT
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| Pt Teaching | RID
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| Rationale 1 | _ is a physiological need, without _it may interfere with his/her abilityto perform ADL's, progress towards healing and involvement in their treatment plan.
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| Rationale 2 | _ is a basic human need. If _ is adequately addressed the patient is more likely to participate in the treatment plan, healing will progress as expected and the patient should return to their pre-hospitalization functionality.
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| physiological needs | breathing-oxygen water-hydration food-nutrition sleep-rest excretion-bodily elimination homeostasis- balance of systems(temp/fluids)
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| Planning phase | 2 nursing dx with outcome and interventions. calculate gravity iv. write down meds to be given se uses teaching points labs h&h pt inr ptt dig na bun last pain med vs adl's
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| 20 min check | wash hands in sight of CE introduce self/CE check iv site-gloves check iv rate/verify solution w/ kardex & amt available verify ngt placement x2 document rate/solution of iv/enteral solution
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| Caring | I CARE
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| Fluid management | Have I drank something-Hids
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| VS | T P R BP WT O2SAT PAIN
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| Asepsis | WASH
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| Physical jeopardy-safety | SCAB
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| Emotional Jeopardy | REALITY
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| Abdominal assessment | 3P's then look listen feel
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| Neurological assessment | LAMP
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| Peripheral Vascular assessment | PTS M CC- post traumatic stress move cc
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| Respiratory assessment | PAIR
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| Skin Assessment | TIME CC
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| Mobility | MAD ATOP
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| Comfort management | COMFORTERS 3
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| Musculoskeletal management | MAP HATR
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| Oxygen management | SOAP
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| Pain management | PAIN
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| Respiratory management | HAIR must do assessment first (PAIR)
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| Wound management | WOUND
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| Medication | WATCH MARS
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| Drain/Specimen | I SPECIAL
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| Enteral Feeding | RAT FEVER
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| Irrigation | IRRIGAT
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| Pt Teaching | RID
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| Rationale 1 | _ is a physiological need, without _it may interfere with his/her abilityto perform ADL's, progress towards healing and involvement in their treatment plan.
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| Rationale 2 | _ is a basic human need. If _ is adequately addressed the patient is more likely to participate in the treatment plan, healing will progress as expected and the patient should return to their pre-hospitalization functionality.
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| physiological needs | breathing-oxygen water-hydration food-nutrition sleep-rest excretion-bodily elimination homeostasis- balance of systems(temp/fluids)
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| IVMB STATION | MMM I GLOVE I GLOVE CDS AOS
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| WOUND PROTECTION STATION | TIGR OPEN PREP GLOVE PAT
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| IV PUSH STATION | MMM CLEAN LABEL CLEAN DIGIWA FGFS
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| IM/SUBCUT STATION | MMM RCAD RIG CAS
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| AOC | Respiratory management musculoskeletal management comfort mangaement oxygen management pain management
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| ND | ineffect airway clear impair phys mob readi for enhan comfort activity intol acute pain
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| I CARE | Introduce/ID w/kardex Choices given Always listen Respond to pt Explain purpose
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| HIDS | Hydration status-turgor fontanel<1 upright I and O's diet/restrictions wt diapers 1gm/1oz encourage fluids Drip rate vol of sol exp date exact on ICD Site check doc in 20 mins
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| Vital Signs | get baseline position properly compare to baseline 30mm document/declare
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| WASH | wash hands always dispose sterile field hands gloved
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| SCAB | side rails up/slippers oncall bell/phone in reach ask need/assess for pain bed in low/locked position
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| REALITY | respect evaluate comfort acceptable language interaction touch yak
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| MAD ATOP1 | mobility status abnormalities devices(does a pt use a brace, walker)ambulate turn offload position must do 1 of the last 4
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| 3 P'S LOOK LISTEN FEEL | potty does pt have to urinate pain is the pt in pain position flat with knees flexed or as low as the pt can tol/privacy look for distention listen for bowel sounds/suction off feel for tenderness rigidity/sx on record data
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| LAMP | LOC- person place and time gen question to child/noxious stimuli asssess fontanelle<1(flat bulging depressed) movement hand grasp/push down and pedal push/pull/strength/symmetry strength PERL
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| PTS M CC | pulses present equal and bil most distal temp warm/cool sensation tactile close eyes most distal movement/motion motor function most distal wiggle toes/fingers color/cap refill <3sec
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| PAIR | position pt upright assess the RRAP rhythm rate accessory muscle use and pattern instruct to deep breathe/listen over skin upper lower bil record
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| TIME CC | temperatureintegrity x2 occiput trochanters heels sacrum/coccygeal skin folds perianal for rash lesion color changes moisture edema present or absent color cap refill
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| COMFORTERS 3 | comfort measures do 3 observe for pain meds prn face wash oral care relaxtion treat with heat or cold evaluate comfort at end reposition simple back rub
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| MAP HATR | mobility status abnormalities pain with movement heat or cold apply devices traction lines free wts free range of motion passive or active
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| SOAP | skin assessment check skin around the cannula face mask- intact red?oxygen status 02 sats cap refill color clubbing activity level assess pt response tired sob? position fowlers
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| PAIN | pain scale assess comfort interventions reposition backrub distraction heat/cold pain meds report to nurse need to reassess record data
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| HAIR | how did pt tol deep breathing? always perform deep breathing and cough 3rd inspiration/provide receptacle incentive spirometry suck in reassess after deep breathing/cough/ics
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| WOUND | wound drainage assessed loc, appearance type observe site unique irrigation & clean sol temp delivery need sterile field dressing
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| WATCH MARS | wash hands acquire meds match med to mar exp date 5 rights(pt med dose route time)take meds in room clean hands w/ meds in site have gloves mar check and 5 rights to pt allergies apical pulse check recheck MAR to meds and give Sign MAR
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| I SPECIAL | ID pt specimen collected place tube properly examine color odor consistency appearance clean surrounding skin I& O recorded assess condition of site label& send
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| RAT FEVER | record amount of formula and type of formula /verify w/kardex in 20 min fowlers examine gastric tube/abdomen verify placement ngt placement by aspiration and instillation of 20 cc air 5cc for pedi and listen record in 20 mins
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| IRRIGAT | Input/verify tube placement reposition pt if necessary right solution & temp instill at correct flow amt of sol used tell all in doc & pt response
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| RID | readinesss to learn mr smith is this a good time to talk about_?identify learning needs- mr smith what do you know about_?does pt understand? mr smith what can you tell me about what we just talked about?
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| MAR MATH MED I GLOVE IGLOVE CDS AOS | ID PT GLOVE ON INSPECT IV SITE GLOVES OFF CLAMP BOTH TUBING DROP PRIMARY BAG SPIKE BAG AIR CHECK AND REMOVE OPEN SECONDARY COMPLETELY/REGULATE W/ PRIMARY SIGN MARS
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| TIGR OPEN PREP GLOVE PAT | TAPE TEAR 4 STRIPS AND INITIAL ONEID PT/ INSPECT DRESSING GLOVES ON REMOVE OLD DRESSING INSIDE OF GLOVE AND DISPOSE OPEN SUPPLIES ABD 4X4 4X4 TRAY SALINE ST GLOVES PREP 4X4 TRAY W/NS GLOVES ON STERILEPACK WOUNDS/COVERW/DRY 4X4 ABD TAPE
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| MMM CLEAN LABEL CLEAN DIGIWA FGFS | CLEAN TOPS OF MEDS LABEL 3 SYRINGES NSX2 MEDSX1 CLEAN NS PORT OF BAG TO DRAW FLUSHES DAW UP FLUSHES/MED CHECK MARID PT GLOVE INSPECT IV SITE VERBALIZE WIPE IV SITEASPIRATE FLUSH W/NS 10-15 SECS GIVE MED OVER PRESCRIBED TIME FLUSH W/NS SIGN MAR
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| MMM RCAD RIG CAS | ROLL CLEAN AIR INJECT NOW THEN RIGHT AWAY DRAW UP RIGHT AWAY VERIFY NOW 2ND VERIFY RECAP PLUNGER STERILE ID PT GLOVE UP CLEAN SITE ABD/VG/VL ASPIRATE 90 DEGREES SIGN MARS
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