Clinical Assessment Preparation

CPNE Study Guide

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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