Clinical Assessment Preparation

CPNE Study Guide

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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