Clinical Assessment Preparation

CPNE Study Guide 2nd Edition 11/15/2018

This study guide is subject to copyright.

Acknowledgements We would like to thank the authors for their patience, support, and expertise in contributing to this study guide; and Christina Wulff for her invaluable efforts in reading and editing the text. We would also like to thank those at Achieve whose hard work and dedication to fulfilling this project did not go unnoticed. Lastly, we would like to thank the Achieve students who have contributed to the growth of these materials over the years. Copyright © 2018 by Achieve All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2017 Achieve PO Box 10188 #29831 Newark, NJ 07101-3188 Tel: 888.900.8380 Visit the Achieve website at http://www.achievetestprep.com/student

CPNE Study Guide

Table of Contents Chapter 1: Lab Stations ....................................................................................................................................... 5 1.1 Wound Management ..................................................................................................................................................6 1.2 Medication Administration................................................................................................................................... 11 Chapter 2: Overriding Areas Of Care............................................................................................................17 Chapter 3: Selected Areas Of Competencies ..............................................................................................19 3.1 Fluid Management.................................................................................................................................................... 19 3.2 Vital Signs .................................................................................................................................................................... 24 3.3 Abdominal Assessment .......................................................................................................................................... 26 3.4 Neurological Assessment....................................................................................................................................... 26 3.5 Peripheral Neurovascular Management .......................................................................................................... 27 3.6 Respiratory Assessment ........................................................................................................................................ 28 3.7 Skin Assessment........................................................................................................................................................ 30 3.8 Comfort Management.............................................................................................................................................. 31 3.9 Musculoskeletal Management ............................................................................................................................. 32 3.10 Oxygen Management............................................................................................................................................. 34 3.11 Wound Management............................................................................................................................................. 35 3.12 Medications.............................................................................................................................................................. 36 Chapter 4: Assessments to complete within the First Twenty Minute Assessments (TMA) ....39 Chapter 5: Evidence-Based Practice Assessment Tools ........................................................................41 Chapter 6: CPNE Nursing Care Plans ............................................................................................................42 Practice Patient Care Scenarios .....................................................................................................................47

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Congratulations on reaching this point of your goal! Passing the CPNE is not impossible, but it does take a lot of preparation in order to be successful. This examination measures your ability to perform as a competent nurse. You will need to utilize assessment skills and techniques that will be reviewed during this workshop. You must perform according to the Critical Elements outlined in your Study Guide. This manual contains a breakdown of the various skills and techniques you will need to master when it comes time for your examination. It is merely a further explanation of each element so that it is easy for you to remember and understand. However, just reading about the skill is not enough. You must practice, practice, and practice!! Also, it is important to read through the entire study guide. In addition to practicing the skills, you must also think about the nursing process. The clinical examination will require you to demonstrate your patient care skills. Proper documentation is also required. The purpose of this guide is to list the required material so that you can gain an understanding of what is expected of you at each step. Please read the entire Excelsior Study Guide for complete information. STUDY AND PRACTICE! • Passing this exam requires the following: • Stress management • Maintaining confidence • Staying positive • Knowing the Critical Elements with 100% accuracy • Perform Critical Elements with 100% accuracy • Effective care plan writing

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Chapter 1: Lab Stations What is the best way to pass lab stations? Practice!! Practice!! Practice!! Important st ps for passing the tw simula ed lab stations: Station 1: Application of Sterile Technique. Students will be randomly assigned to complete one of the following: • Wound management • Change PICC line dressing • Insert an intermittent urinary catheter The student will be presented with a case scenario and patient data and is to use nursing judgment to determine the procedure (from the list above) to be performed. The student will perform the procedure and document. The student will have 30 minutes to complete this lab skill station. At the beginning of this NSL station, the CE will: • Welcome the student • Provide a brief orientation to the station • Provide the following information for the assigned patient: a) Patient scenario b) Medical record [includes treatment record, medication administration record (MAR), vital signs flow sheet, laboratory results, and imaging results] c) SBAR (Situation, Background, Assessment, Recommendation) • Provide student with start and scheduled end time for the station The student is expected to: • Perform all Critical Elements with 100% accuracy • Review patient data included in the patient scenario, medical record, MAR, and SBAR • Demonstrate nursing judgment by analyzing patient data to determine the appropriate procedure to perform • Perform procedure using the proper techniques • Document - NURSING SIMULATION LABORATORY - Application of Sterile Technique for Common Procedures Form • Complete the station within the established timeframe

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1.1 Wound Management • Assemble your equipment. Equipment should include: a) A bottle of saline b) Tray of 4x4 sponges c) ABD pad d) Single 4x4 gauze e) Paper tape f) A pair of clean gloves g) A pair of sterile gloves h) A container to dispose of soiled dressing You can purchase a wound from Excelsior to practice on or you can create your own wound with modeling clay or putty. Important: Be mindful of your time and maintain sterile techniques! • Assess wound a) Type b) Location c) Condition of wound bed d) Presence or absence of drainage e) Condition of surrounding skin • Prepare supplies using sterile techniques • Maintain asepsis • Maintain sterile techniques when indicated • Wound management dressing: a) Remove the dressing without contaminating the wound b) Dispose of the dressing in the designated container c) Prepare packing with prescribed solution d) Cleanse wound with normal saline Pack wound by: 1. Applying one sterile moist dressing to wound bed surface 2. Applying a loosely fluffed dressing to wound bed surface 3. Applying moist dressing so that the gauze does not extend beyond the top of the wound 4. Applying sterile dressing without contaminating the wound 5. Covering packed wound with sterile 4x4 6. Covering 4x4 with sterile ABD pad 7. Securing the dressing 8. Labeling dressing with the date, time, and initials

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Important Steps to Remember: 1. Organize the equipment. Try to set it up in the order of use. Reaching over your sterile field will result in failure. 2. Open the 4x4s, ABD pad, and sterile dressing tray AWAY from you. 3. Pour a small amount of sterile saline onto the 4x4s in the sterile tray. Do not drench the sponges. 4. Put on the clean gloves. 5. Loosen the tape of the existing dressing, and pull up and away from you to dispose. 6. Wrap the old dressing in your clean glove and discard in the garbage container. 7. Put on sterile gloves. Use sterile technique as directed by instructor. If you break the sterile field at any time, remove both gloves and start over. 8. Remove the top wet sponge from the sterile tray and squeeze out excess saline over remaining sponges. 9. Pull apart the wet sponge to create a lose packing. 10. Starting at one end of the wound, place the edge of the sponge in it, packing it gently and keeping the gauze loose and fluffed. Be sure to cover the entire wound bed. Do not move the gauze once it is in place. If you touch intact skin with the sponge, remove it, replace your gloves, and start again. 11. Place dry 4x4 over the wound. 12. Apply the ABD pad and be sure the absorbent part is towards the dressing. 13. Remove gloves and apply tape to all four sides. 14. Write the date, time and your initials on a small piece of tape and apply to corner of dressing. Document: 1. Pertinent data associated with the clinical decision to support why you chose the Wound Management Application of Sterile Technique as the Simulated Lab skill to perform. 2. Assessment data for wound: a) Procedure performed b) Type of wound c) Location d) Condition of wound bed e) Presence or absence of drainage f) Condition of surrounding skin • Complete procedure withi 30 minutes! • Adhere to professional behaviors • Perform procedure with the allotted supplies

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Changing PICC Line Dressing: • Assess PICC line dressing: a) Appearance of insertion site (e.g., redness, inflammation) b) Presence or absence of drainage c) Insertion date d) Condition of dressing e) Last dressing change date f) Length of PICC Line • Prepare supplies using sterile technique • Maintain asepsis • Maintain sterile technique when indicated • Change PICC line dressing, if appropriate a) Remove dressing without contaminating the site b) Dispose of soiled dressing in the designated container c) Prepare dressing supplies using sterile technique d) Cleanse the site e) Apply transparent dressing without contaminating the site f) Secure line with tape to skin g) Label dressing with date, time, and initials

Important Steps to Remember: 1. Organize the equipment. Try to set it up in the order in which you will use it. Reaching over your sterile field will result in failure. 2. Open the PICC line dressing kit away from you. 3. You may remove the mask without touching anything else in the sterile kit. Put on the face mask with the white side facing you and the blue side facing the patient. 4. Put on a pair of clean gloves. 5. Gently peel off the old dressing. DO NOT pull or touch the catheter where it comes out of the arm. 6. Throw away the old dressing and gloves. 7. Wash your hands and put on a new pair of sterile gloves. 8. Check the skin for redness, swelling, bleeding, or any other drainage around the catheter. During the dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred. 9. Squeeze the sides of the Chloraprep stick contained in the package and clean the site using a circular motion. Begin sterilizing at the insertion site and work in an outward motion. 10. Allow the area to dry on its own for at least 30 seconds. Cover the insertion site with clear dressing. 11. Secure the PICC line with tape to skin. 12. Label dressing with date, time, and initials.

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Document: • Assessment data for PICC line: a) Appearance b) Presence or absence of drainage c) Time of dressing change d) PICC line length • Adhere to professional behaviors • Perform procedure with allotted supplies • Complete procedure within 30 minutes! • Insert intermittent urinary catheter as indicated  Respect privacy a) Drape mannequin before procedure b) Cover mannequin after procedure • Select correct catheter size • Apply sterile underpad • Cleanse urinary meatus with swab • Discard cleansing materials in appropriate container • Position urine receptacle • Insert lubricated catheter 2-3 inches (5.08-7.62 cm) for female or 5-7 inches (12.7-17.78 cm) for male • Withdraw catheter • Dry perineal area with underpad • Discard supplies Document: • Assessment data for intermittent catheterization: a) Data related to urinary status b) Time of current catheterization c) Size of catheter • Adhere to professional behaviors • Perform procedure with allotted supplies • Complete procedure within 30 minutes! Medication Administration NSL Station: The student is expected to complete the Critical Elements for this station within 30 minutes and with 100% accuracy. The student will be presented with a case scenario, patient data, and the Medication Administration Record (MAR), and is expected to use nursing judgment to analyze patient data to determine the medications to be administered during the simulation. The student will prepare and administer the medications and document.

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The student will be assigned up to six medications via three of the following routes: • Oral • Intravenous push (IVP) • Intravenous mini bag (IVMB) • Intramuscular injection (IM) • Subcutaneous injection (subQ) At the start of this NSL station, the CE will: • Welcome the student • Provide a brief orientation to the station • Provide the following information for the assigned patient: a) Patient scenario b) Medical record (includes treatment record, vital signs flow sheet, laboratory results, and imaging results) c) Medication administration record (MAR) d) SBAR (Situation, Background, Assessment, Recommendation) • Provide student with start and scheduled end time for the station The student is expected to: • Perform all Critical Elements with 100% accuracy • Review patient data included in the patient scenario, medical record, MAR, and SBAR • Demonstrate nursing judgment by analyzing patient data to determine appropriate medications to administer • Prepare medications using proper techniques • Administer medications safely and accurately using the following routes: a) Oral b) Intravenous push (IVP) c) Intravenous mini bag (IVMB) z intramuscular injection (IM) z subcutaneous injection (subQ) • Document • Complete the station within the established timeframe During the NSL station, the CE will verify if the student has completed all Critical Elements. If the student has not, the CA will be consulted.

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1.2 Medication Administration Demonstrates nursing judgment by analyzing patient data to determine the appropriate medications to administer. The student will prepare and administer the medications, and document in a simulated setting. Critical Elements for Medication Administration: • Perform hand hygiene • Verbally identify the patient by comparing two of the following pieces of information on the patient’s identification band against the MAR:  Patient name  Date of birth  Medical record number • Maintain asepsis • Assess: 1. Pertinent patient data associatedwith assigned medications (e.g., laboratory values, vital signs) 2. IV site • Implement: 1. Identify the indication for use of each medication in relation to the patient’s current clinical condition 2. Verbalize correct decision on whether the medication(s) can be administered or need to be withheld based on pertinent patient data 3. Calculate and record the correct dose on the calculation and recording form 4. Prepare the assigned medication(s) for administration: a) Select the prescribed assigned medication(s) using the MAR b) Prepare medication using the proper technique c) Measure the prescribed dosage(s) d) Label container with drug name, strength, and amount, if medication is unidentifiable 5. Administer medications: a) Use the prescribed route b) Administer prescribed medication as indicated c) Administer one medication at a time d) Administer injectable medication as assigned  Select correct syringe  Select correct needle gauge  Select correct needle length  Cleanse medication hub before every entry  Cleanse injection site prior to administration  Select appropriate site  Apply pressure after injection  Use proper technique e) Administer intravenous medication as assigned

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 IV Mini Bag:  Determine drug compatibility Spike the bag  Prime tubing before initiating flow of IV medication  Clear air from tubing before initiating flow of IV medication  Lower primary IV bag onto the hanger on IV pole. Mini bag will need to be higher than primary bag  Open clamp on secondary tubing  Place wristwatch in one hand. With the other hand, slowly open IV clamp on primary line  Start counting to regulate the drip rate according to your calculations. Try to divide your total one-minute rate by 4 to get a rate for 15 seconds  Regulate flow rate to deliver the prescribed amount in the assigned period of time (+/- 5 drops per minute for medication delivered via gravity flow)  Maintain sterile technique  When you are within 2-3 drops of the calculated rate, remove your hand from clamp and count for one whole minute  Declare that you are ready to verify your drop rate. You are allowed to be within plus or minus 5 drops  IV Push:  Clean off top of medication vial with alcohol wipe  Put on clean gloves and assess IV site  Cleanse the port with alcohol wipe  Aspirate for blood return unless contraindicated when an intermittent venous access device is used  Flush with prescribed solution before IV push medication  Give flush slowly over 8-10 seconds  Inject the medication at the assigned rate  Flush with prescribed solution after IV push medication Use 15 second intervals to be sure you are keeping time. Be SLOW  Maintain sterile technique 1. Maintain environmental safety a) Discard unused medication and/or packaging in the designated container b) Engage safety device on needle prior to discarding c) Dispose of syringes and needles in designated medical waste container 

Document: Record on the MAR Prior to Administering Medication: 1. Correct indication for use of medication(s) 2. Pertinent patient data associated with assigned medications on the MAR

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Immediately after Administering Medication: 1. Student name, initials, and ECSN on the signature section of the MAR 2. Initials in the initials section for each medication 3. Assessment data to support reason for not giving a medication 4. Site of injectable medication 5. Condition of site for IVMB or IV push Complete all Critical Elements within 30 Minutes: • Adhere to professional behaviors • Perform procedure with allotted supplies Important Tips: ** Read MAR carefully to ensure you are choosing the correct medication and proper dose. ** You will be checked at quarterly intervals to ensure you are administering the medication over the proper time. Be mindful of this time. Helpful Formula for IV Push Medication: Drug Available/ Amount of Solution = Dose Wanted/ Amount Desired **Practice drug calculations to determine IV flow rate Equation for IV Flow Rate Calculation: Volume to be infused (mL) x Drop factor = Drops/minute Time (in minutes) Creating “The Grid” for CPNE Patient Care: Creating a grid can be helpful to remind you of the areas of competencies. Four to five AOCs are assigned in each PCS based on the patient’s current clinical condition. FOR ALL AOC (excluding VS/Abdominal/Neurological), YOU MUST DO PATIENT TEACHING You may want to write this on the back of your patient care record.

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Mobility Mobility status Abnormality of gait Devices Ambulate Turn Offload Position Transfer Response Record Respiratory Management Position Assess Instruct deep breaths Gloves Receptacle O2 sats Resp hygiene intervention Treatment ordered (DB&C, IS) Reassess Secretions • Presence • Amount • Color • Consistency • Odor Document presence before and after interventions

Abdominal Assess Pee Pain Privacy Position Suction off Look Listen Feel Suction on Skin Assessment Braden Pressure Scale Color changes Temp Integrity Moisture Edema Have to assess one vulnerable skin surface based on patient’s condition Perform two interventions to keep skin intact • Keeping skin clean • Applying protective products to the skin • Reposition • Apply a pillow under the legs to “float” the heels

Ne ro Assess LOC Level of arousal • Verbal • Tactile Assess: Fontanel <1yr Movement • Squeeze hands • Plantar/dorsifl ex feet PERRLA • Noxious stimuli unresponsive Comfort Management Assess comfort EBP Scale • • Comfort Verbal Rating Ask patient about what makes them comfortable Perform 2 interventions Reassess comfort Comfort Daisies

Peripheral Neurovascular Assess Pulse Movement Sensation Temp Color Perfusion (capillary refill) Edema Perform 2 interventions to improve circulation Warmth Activity/exercise SCDs/stockings Position Pain Management Assess pain • Level • Location • Quality • Duration 3 measures Medicate/report to RN Reassess pain

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Suctioning Position Semi- Fowler’s Assess Gloves, gown, glasses O2 sats Set suction pressure Trach kit or oral suction Hyper-oxygenate Insert catheter Suction for NO MORE than 15 seconds each time Deep breathing after suctioning Repeat as needed after 30 seconds Oral care after final suction Reassess lung status Bulb suctioning Insert bulb syringe into mouth or nares and wear gloves

Oxygen Management Skin assessment • Ears • Nares O2 sat/rate O2 delivery device Activity level Position upright Safety-No sparks

Wound Management Gloves Assess (color/drainage) Irrigate Clean wound Topical meds Label (time, date, initials) Dressing Response

Musculoskeletal Manage. Morse Fall Scale Mobility status Strength Abnormalities/appear ance Pain w/movement Heat/cold Apply devices Traction ROM • Ab/Adduct OR • Flex/Extend Activities performed Alignment Call bell Alarms Nonskid socks Response

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Drainage Collection Assess color & amount Clean skin Insert and hold tube Remove tube Spec. Collection Check hospital policy Container Obtain specimen Label- (date/time/initials) Place in designated area Record color & amount

Enteral Feeding Record rate (20 min check) Amount Type of feeding Fowler’s position Examine GT site Verify placement Expiration of formula Record

Irrigation Solution Temperature Position patient Placement (if NGT) Instill solution Protect surrounding skin Rate of flow Receptacle-For return Record type & amount

Patient Teaching Readiness to learn ID learning needs Does patient understand? Medications Compare Kardex & MAR 5 rights ID patient Gloves if needed Inspect site of medication Administration Site of vital signs taken Assess patient’s pain using scales Tell CE if you are not giving meds Educate patient Administer one med at a time Recheck MAR against patient ID Evaluate patient response to med Condition of IV site before and after med Sign MAR within 30 min and fill out entire sheet

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Chapter 2: Overriding Areas Of Care

Plan of Care: Student makes nursing judgment evident by developing, evaluating, and recording a plan of care to meet the unique needs of the assigned patient. The plan of care will be recorded on the plan of care form. Safe Patient Care: Student creates and maintains an environment that safeguards the patient’s physical and emotional well-being throughout the PCS. Create a safe care environment at the beginning of the implementation phase: 1. Perform hand hygiene using soap and water in the presence of the clinical examiner. 2. Introduce yourself. 3. Verbally identify the patient by comparing two of the following pieces of information on the patient’s identification band against the PCS Assignment. a) Medical record number Establish a therapeutic relationship with the patient: 1. Individualize communication based on the patient and family’s unique characteristics. 2. Inquire about the preferred method of being addressed. 3. Inform patient about the nature of care to be provided. 4. Maintain patient’s privacy. 5. Touch the patient as appropriate and remain culturally sensitive (e.g., with non- communicative patient or a child). 6. Encourage and appropriately respond to patient needs and desires (both verbal and non- verbal expressions). 7. Allow patient to voice choices as appropriate. 8. Maintain a professional dialogue and behavior at all times. Demonstrate nursing judgment throughout the entire PCS: 1. Provide care consistent for the patient’s current clinical condition. 2. Maintain assigned precautions (e.g., fall, hip, sternal). 3. Modify/omit a critical element(s) in an overriding or assigned area of competency in response to clinical data collected while caring for the patient. 4. Document the reason for the modification or omission of critical element(s) within the assigned area of competency. Patient name b) Date of birth c)

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5. Implement nursing intervention(s) without delay to address a change in the patient’s current clinical condition. 6. Communicate with assigned nurse without delay when a patient condition warrants immediate attention. 7. Respond promptly to clinical alarm systems by notifying assigned nurse or CE. 8. Use proper technique to perform interventions. 9. Act in a manner that prevents patient harm (e.g., not leaving medications unattended). Maintain a safe physical environment throughout the entire PCS: 1. Involves anything that you do or do not do for the patient that would threaten their physical well-being. 2. The clinical examiner monitors that you are maintaining a safe physical environment throughout the entire process of the PCS. 3. Keep floor dry and clear of clutter. 4. Maintain bed in low position when patient is unattended. 5. Keep call bell in patient’s reach. 6. Elevate bed rails when indicated. 7. Lock wheeled furniture when stationary. 8. Keep crib rails up at all times when not providing patient care. 9. Keep infants/children within reach during care when side rail is down. 10. Keep infants/children within visual line of sight during care when side rail is down. 11. Secure infant/child when out of bed to infant seat/highchair. 12. Act in a manner that prevents patient harm during activity (e.g., do not leave child unattended while out of bed). Maintain standard precautions throughout the PCS: 1. Perform hand hygiene using soap and water or alcohol-based (waterless) hand rub when: a) Entering a patient room b) Exiting a patient room c) Before and after patient contact d) Before and after wearing gloves e) After picking up anything from the floor f) Before entering a med room or touching a medication cart 2. Perform hand hygiene using soap and water or alcohol-based (waterless) hand-rub when indicated throughout the PCS. 3. Clean general use equipment per hospital policy. 4. Use standard personal protective equipment (PPE) when indicated. 5. Protect environment, patient, and self from contaminants (e.g., blood-borne pathogens). 6. Dispose of contaminated material in the appropriate container.

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Chapter 3: Selected Areas Of Competencies 3.1 Fluid Management Assess hydration status by two of the following methods : • Inspect mucous membranes • Check skin turgor • Palpate anterior fontanel under 1 year of age in upright position o Document on Fluid Management Flow Sheet Continuous enteral feeding, when assigned: Perform the following within 20 minutes after starting implementation: • Assess: 1. Verify feeding formula being infused is the same as noted on PCS Assignment 2. Verify flow rate is the same as noted on PCS Assignment 3. Inspect the integrity of the system 4. Inspect the appearance of skin surrounding entry site:  Type of fluid to be administered  Restriction as designated  Encourage fluids assigned; need to offer at least once • Implement: 1. Notify CE and/or assigned nurse immediately if flow rate of enteral feeding is not as noted on PCS Assignment 2. Measure gastric residual, when assigned 3. Reinstill gastric residual, when assigned 4. Regulate flow rate to deliver prescribed volume of feeding 5. Ensure patient receives prescribed volume of feeding • Evaluate: 1. Patient response to feeding • Document on Fluid Management Flow Sheet: 1. Within 20 minutes after starting implementation 2. Feeding formula 3. Flow rate 4. Integrity of system 5. Appearance of skin surrounding entry site 6. Volume (mL) of enteral feeding during PCS within +/- 10% of actual intake during planning and implementation 7. Indicate time of measurement 8. Place initials in appropriate box on Fluid Management Flow Sheet 9. Amount of gastric residual 10. Amount of gastric residual reinstilled 11. Patient response to feeding

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Bolus enteral feeding, when assigned: • Assess: 1. Inspect integrity of system 2. • Implement: 1. Measure gastric residual, when assigned 2. Reinstill gastric residual, when assigned 3. Initiate assigned enteral feeding within +/- 30 minutes of scheduled time 4. Regulate flow rate to deliver prescribed volume of feeding 5. Ensure patient receives prescribed volume of feeding • Evaluate: 1. Patient response to feeding • Document on Fluid Management Flow Sheet: 1. Feeding formula 2. Flow rate 3. Integrity of system 4. Appearance the of skin surrounding entry site 5. Volume (mL) of enteral feeding during PCS within +/- 10% of actual intake during implementation 6. Amount of gastric residual 7. Amount of gastric residual reinstilled 8. Patient response to feeding Oral enteral fluids, when assigned: • Implement: 1. Encourage fluids, when assigned 2. Restrict fluids, when assigned 3. Thicken liquids, when assigned 4. Feed infant, when assigned 5. Encourage mother to breastfeed 6. Prepare bottle with formula as noted on PCS Assignment 7. Provide bottle to infant 8. Burp infant periodically during feeding and as necessary 9. Measure intake of enteral fluids • Evaluate: 1. Patient response to feeding • Document on Fluid Management Flow Sheet: 1. Type of enteral fluid intake (e.g., water, breastfed, Enfamil) 2. Amount of each enteral fluid, in mL (e.g., 120 mL) or time (e.g., 10 minutes on each breast) within 10% of actual intake during implementation 3. Patient response to feeding Inspect appearance of skin surrounding entry site

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Parenteral fluids, when assigned: Perform the following within 20 minutes after beginning of implementation: • Assess: 1. Inspect insertion site for complications using both Count calculated drops per minute for gravity flow 4. Verify IV solution is the same as noted on PCS Assignment 5. Inspect integrity of system:  Dressing intact  Tubing secured 6. Inspect tubing for kinks and air • Implement: 1. Notify CE and/or assigned nurse immediately if any of the following is present:  IV insertion site has evidence of complications  mL per hour are not the same as noted on PCS Assignment  Request CE change mL per hour on infusion control device if a change is needed 4. Regulate drops per minute to within +/- 5 drops per minute (regular or microdrops) of calculated drops per minute when gravity flow is assigned 5. Administer/maintain assigned IV solution Discontinue IV fluid, when assigned: • Remove cannula • Cover site with dressing Convert continuous IV to IVAD, when assigned: • Attach cap to present IV site after removing the IV line • Flush IVAD with prescribed solution If new IV solution needs to be hung during PCS, perform the following: • Determine flow rate in mL/hour if delivered via ICD or drops per minute via gravity flow • Prime IV tubing, if necessary • Ensure there is no air in tubing • Ensure there is no kinks in tubing • Verbally identify the patient immediately before administration of new IV solution by verifying two of the following pieces of information on the patient’s identification band against the PCS Assignment Air is noted in tubing 2. Remove kinks from tubing 3. of the following methods:  Observe surrounding skin for changes in color  Palpate surrounding skin for edema 2. Determine drops per minute if IV solution is delivered via gravity flow 3. Verify the flow rate is the same as noted on PCS Assignment by one of the following:  Observe mL per hour setting on infusion control device 

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   Patient name Date of birth Medical record number • Reassess insertion site for complications using both  Observe surrounding skin for changes in color  Palpate surrounding skin for edema • Administer new solution by:  Hang new solution  • Measure amount of parenteral fluid infused (informs CE) • Evaluate: 1. Patient response to parenteral intake • Document on Fluid Management Flow Sheet: 1. Within 20 minutes after beginning of implementation:  IV solution  IV flow rate  Condition of IV insertion site • If IV solution changed 1. New IV solution 2. Flow rate for new solution 3.

of the following methods:

Request CE set ICD for calculated mL per hour  Regulate drops per minute within +/- 5 drops per minute (regular or microdrops) of calculated drops per minute

Condition of IV insertion site prior to start of new IV solution • Volume (mL) of parenteral intake during PCS within +/- 10% of actual intake during planning and implementation • Indicate time of measurement • Place initials in appropriate box on Fluid Management Flow Sheet • Patient response to parenteral intake Intermittent intravenous access device, when assigned: • Assess: 1. Insertion site for complications using both of the following methods:  Observe surrounding skin for color changes  Palpate surrounding skin for edema • Implement: 1. Use correct syringe 2. Aspirate for blood return, unless contraindicated 3. Flush with prescribed solution • Evaluate: 1. Patient response to flush 2. Insertion site after flush for complications using the following methods 3. Observe surrounding skin for color changes, and 4. Palpate surrounding skin for edema • Document on Fluid Management Flow Sheet:

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Condition of insertion site Type of flush used Amount of flush (mL)

1. 2. 3. 4.

Patient response to flush Drainage devices, when assigned: Perform the following within 20 minutes after beginning of implementation: • Assess:  Verify type of suction, if applicable  Verify amount of suction, if applicable  Inspect integrity of system 1. Indwelling urinary catheter secured to leg 2. Occlusive dressing to chest tube 3. Ostomy bag secured 4. Nasal gastric tube secured 5. Surgical drain secured  Inspect condition of skin surrounding insertion site  Baseline characteristics of drainage (e.g., quantity, color) a. Type b. Color • Implement: 1. Maintain or attach drainage device to appropriate container 2. Maintain patency of drainage device 3. Ensure drainage device is stabilized 4. Empty drainage device when needed 5. Measure amount of fluid in or removed from drainage device 6. Remove drainage device, when assigned • Evaluate: 1. Patient response to drainage device 2. Patient response to removal of drainage device, when assigned • Document on Fluid Management Flow Sheet: 1. Type of drainage device 2. Site of drainage device 3. Type of suction 4. Amount of suction 5. Integrity of system 6. Condition of skin surrounding insertion site 7. Drainage type 8. Drainage color 9. Drainage amount (mL) within +/- 10% of actual output during planning and implementation 10. Patient response to drainage device 11. Patient response to removal of drainage device, when assigned

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Output, when assigned alone or when assigned with rainage device(s): • Assess:  Type of output (e.g., urine, emesis, stool, drainage)  Amount of output at beginning of implementation  Color of output • Implement:  Collect output  Measure output • Document on Fluid Management Flow Sheet:  Type of output  Amount of output (mL) within +/- 10% of actual output during implementation  Indicate time of measurement  Place initials in appropriate box on Fluid Management Flow Sheet  Color of output The CE will record the amount of fluid left in the bag (continuous enteral feeding and/or parenteral fluids) and the amount in drainage devices while the student is in the planning phase. Students are reminded there is a number of timed Critical Elements within this AOC, and students will document on the Fluid Management Flow Sheet and the clinical notes. The CE will ask to view the student’s PCS Assignment and Documentation form 20 minutes after implementation starts to verify the student has accurately completed the timed Critical Elements. 3.2 Vital Signs • All assigned vitals will have a check next to the them on the PCS Assignment Kardex and be taken simultaneously with the CE • Practice using the equipment during orientation • Students will be expected to perform manual blood pressures whenever blood pressure is assigned • Once a complete set of vital signs has been obtained by the student, the Clinical Examiner will determine the accuracy • Students are to document in the clinical notes section of the PCS Assignment and Documentation form • Establish a baseline for assigned patients • Any changes need to be reported to the staff nurse • If a child is fussy, you can defer until later in the implementation phase • Determine the appropriate pulse location based on the patient’s current clinical condition • Determine the appropriate method of pain assessment based on the patient’s current clinical condition • Measure assigned vital signs using proper technique  Measure oxygen saturation  Measure pain level using one of the methods below based on patient’s current clinical condition:

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1. Numeric Rating Scale 2. FACES Pain Rating Scale 3. FLACC Pain Assessment Tool 4. Observed behaviors

• Guidelines:  Length of time for holding a thermometer  Size and position of BP cuff  Placement of stethoscope  Avoiding do not use arm (arm with dialysis shunt)  Direct skin contact with stethoscope Oral, axillary, temporal, tympanic, or rectal; will be designated on PCS  Wear gloves!  Document temperature to the exact degree  Document site where temperature is assessed • Apical/radial pulse (within +/- 5 beats for adults, +/- 10 beats for 2 years and under) and respirations (within +/- 2 respirations per minute for adults, +/- 6 respirations per minute for patients under 2 years)  Count for a full minute  Can change from radial to apical, but not apical to radial  Need to inform the instructor of the length of counting time  Always assess directly on skin  Document site where pulse is assessed • Blood pressure (+/- 6 mm)  Chose appropriate size cuff  Bell or diaphragm can be used  Wait 1 minute between each BP assessment  Pump cuff to 30 mm higher than baseline  Document site where blood pressure is obtained • Oxygen saturation  Review unit protocol parameters  Reported values will be established on Kardex  Document oxygen saturation level to the exact percentage  Document oxygen delivery rate  Document oxygen delivery method • Pain level  Scales; 0-10, analog, faces, FLACC • When using the FLACC scale, the CE will need to do this at the same time • Review child growth and development  Observation of pain behaviors  Need to intervene for pain even if pain management is not assigned as an area of care  Document pain level to the exact number or description of observed behavior  Document method used for pain assessment • Temperature (within 0.2 degrees) 

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3.3 Abdominal Assessment • Ask the patient if they need to void • Ask if the patient is experiencing any pain • Position the patient supine with knees flexed • Suspend gastric suction prior to auscultation when indicated • Reestablish gastric suction immediately after auscultation • Assess:  Perform assessment techniques in proper sequence  Inspect the abdomen for: 1. Appearance (e.g., drains, incision site, dressing, discoloration) 2. Contour (e.g., flat, round, distended, convex, concave)  Auscultate for bowel sounds in all abdominal quadrants  Perform light palpation in all abdominal quadrants, assessing for: 1. Tenderness or pain 2. Muscle resistance (e.g., soft, firm, rigid) • Document:  Appearance of abdomen  Contour of abdomen  Bowel sounds in all quadrants  Tenderness or pain  Muscle resistance

3.4 Neurological Assessment • LOC: Level of consciousness – person/place/time/familiar objects • Observe a 1 to 3-year-old child or non-communicating child/adult’s ability to recognize familiar people or common objects in the environment • Palpate anterior fontanel when indicated: Assess for child < 1 yr. Upright position, depressed, flat, or bulging • Pupils: equal and round, reaction to light (e.g., brisk, sluggish, fixed) • Determine equality of muscle strength/motor response in upper and lower extremities:  Ask the responsive patient to: 1. Squeeze student’s fingers simultaneously with both hands 2. Dorsiflex both feet simultaneously against resistance 3. Plantarflex both feet simultaneously against resistance • Observe motor response(s) in a child under 3 years of age or a non-communicating child/adult:  Symmetry in the upper extremities  Symmetry in the lower extremities  Movement in the upper extremities  Movement in the lower extremities • Document:  Level of arousal

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  Characteristics of anterior fontanel when indicated  Equality of pupil size  Pupil reaction to light  Equality of muscle strength in upper extremities  Equality of muscle strength in lower extremities  Equality of motor response in upper extremities  Equality of motor response in lower extremities Level of orientation

3.5 Peripheral Neurovascular Management • Assess:  Perform bilateral comparison of the most distal area of the assigned extremities by assessing for: 1. Color 2. Capillary refill 3. Motor function  Ask patient to move assigned extremities  Observe movement of assigned extremities in a child under 3 years of age or a non- communicating adult 4. Sensation 5. Provide education based on learner needs  Perform two appropriate interventions, based on the patient’s current clinical condition, directed toward improving circulation, such as: 1. Position affected extremity(ies) 2. Keep extremity(ies) warm 3. Provide exercise 4. Maintain/apply sequential compression device or anti-embolism stockings 5. Other appropriate intervention(s) • Document:  Education provided  Learner understanding of education provided  Assessment data of bilateral comparison of the most distal area of the assigned extremities: 1. Capillary refill 2. Color 3. Motor function 4. Sensation 5. Temperature Temperature 6. Pulse quality 7. Edema • Implement: 

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6. Pulse location 7. Pulse quality 8. Edema

• Interventions implemented for peripheral neurovascular management • Patient response to interventions implemented Position patient to facilitate respiratory assessment • Perform assessment on bare skin • Position stethoscope over intercostal spaces • Instruct patient to breathe in and out slowly and deeply • Provide a receptacle to receive secretions as needed • Listen to the upper then lower, comparing side to side and top and bottom • Observe how the patient is managing their breathing • Assess:  Determine learner need(s) related to respiratory management  Determine respiratory status prior to hygiene interventions  Count respiratory rate  Observe respiratory depth  Observe respiratory rhythm  Observe respiratory effort  Measure oxygen saturation level to exact percentage 1. Observe oxygen delivery rate 2. Observe oxygen delivery method  Determine presence or absence of secretions • Implement:  Provide education based on learner needs  Perform respiratory hygiene interventions 

3.6 Respiratory Assessment •

Direct performance or perform respiratory hygiene intervention(s) based on patient’s current clinical condition 1. Deep breathing exercises 2. Coughing exercises 3. Direct patient to breathe in and out as deeply as possible 4. Direct patient to cough forcefully on third or fourth expiration 5. Direct patient to splint while coughing, if appropriate 6. Device exercises using the appropriate device for the amount of repetitions noted on the PCS Assignment (e.g., incentive spirometer, pin wheels, blowing bubbles)

• Provide oral care after hygiene activities

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CPNE Study Guide using assigned device (e.g., closed or open): • Explain the procedure to the patient • Maintain sterile technique throughout suctioning • Monitor oxygen saturation during the procedure • Set suction pressure • Verify patency of the catheter • Hyperoxygenate at prescribed liter flow as needed • Insert catheter gently into trachea • Close control valve after device has been inserted • Rotate catheter continuously during suctioning • Suction for no more than 15 seconds at a time • Have patient take deep breaths after suctioning • Repeat steps if additional suctioning is needed Oral suction using oral suction device: • Explain the procedure to the patient • Monitor oxygen saturation during the procedure • Set suction pressure • Verify patency of the suction device • Insert suction device gently into oral cavity • Close control valve after suction device has been inserted • Suction for no more than 15 seconds at a time • Have patient take deep breaths after suctioning • Repeat steps if additional suctioning is needed Bulb syringe suction: • Deflate bulb syringe prior to insertion • Insert bulb syringe into the patient’s mouth • Insert bulb syringe into nares • Aspirate secretions • Document:  Education provided  Learner understanding of education provided Assessment before interventions: • Respiratory status • Tracheal suction

Respiratory rate within established parameters of +/- 2 respirations/ minute for patients 2 years or older or +/- 6 respirations/minute for patients under 2 years • Respiratory depth

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• • Respiratory rhythm Respiratory effort • Breath sounds in bilateral upper and lower lung fields • Oxygen saturation level to exact percentage • Oxygen delivery rate • Oxygen delivery method • Presence or absence of secretions • Respiratory hygiene intervention(s) implemented Evaluation after interventions: • Respiratory status •

Respiratory rate within established parameters of +/- 2 respirations/ minute for patients 2 years or older or +/- 6 respirations/minute for patients under 2 years • Respiratory depth • Respiratory rhythm • Respiratory effort • Breath sounds in bilateral upper and lower lung fields • Oxygen saturation level to exact percentage • Secretions:  Presence or absence  Amount  Color  Consistency  Odor, if present • Oral care provided • Patient response to interventions implemented Determine learner need(s) related to skin management  Predict accurate pressure ulcer risk using the Braden Scale for Predicting Pressure Sore Risk  Select one impaired/susceptible skin surface based upon the patient’s current clinical condition (bilateral comparison of symmetrical body parts is expected) • Ears • Elbows • Heels • Sacral/ Buttock area • Skin Folds • Trochanters

3.7 Skin Assessment • Assess: 

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Other

•  Assess impaired/susceptible skin surfaces for: • Color changes (e.g., blanchable, non-blanchable, ethnic variations) • Edema • Integrity • Moisture level status (e.g., moist, dry) • Temperature (e.g., warm, hot, cool) • Turgor Provide education based on learner needs  Implement two nursing interventions to prevent alterations in skin integrity/maintain skin integrity based on patient’s current clinical condition, such as: • Reposition • Apply/maintain redistribution devices • Keep skin clean • Provide incontinence care • Apply protective products • Other appropriate intervention(s) • Document:  Education provided  Learner understanding of education provided  Total score on Braden Scale for Predicting Pressure Sore Risk  Assessment data for selected impaired/susceptible skin surfaces: • Location • Color changes (e.g., blanchable, non-blanchable, ethnic variations) • Edema • Integrity (e.g., altered, not altered) • Moisture level status (e.g., moist, dry) • Temperature (e.g. warm, hot, cool) • Turgor • Nursing interventions implemented to prevent alterations in skin integrity/maintain skin integrity • Patient response to interventions implemented • Implement: 

3.8 Comfort Management • Assess: 

Determine learner need(s) related to comfort  Determine comfort using one of the methods below: • Comfort Verbal Rating Scale • Comfort Daisies Scale • Observed behaviors indicative of discomfort  Establish patient preferences for addressing comfort needs

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