Clinical Assessment Preparation

CPNE Study Guide

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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