Clinical Assessment Preparation

CPNE Study Guide

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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