Clinical Assessment Preparation

CPNE Study Guide

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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