Clinical Assessment Preparation

CPNE Study Guide

  Characteristics of anterior fontanel when indicated  Equality of pupil size  Pupil reaction to light  Equality of muscle strength in upper extremities  Equality of muscle strength in lower extremities  Equality of motor response in upper extremities  Equality of motor response in lower extremities Level of orientation

3.5 Peripheral Neurovascular Management • Assess:  Perform bilateral comparison of the most distal area of the assigned extremities by assessing for: 1. Color 2. Capillary refill 3. Motor function  Ask patient to move assigned extremities  Observe movement of assigned extremities in a child under 3 years of age or a non- communicating adult 4. Sensation 5. Provide education based on learner needs  Perform two appropriate interventions, based on the patient’s current clinical condition, directed toward improving circulation, such as: 1. Position affected extremity(ies) 2. Keep extremity(ies) warm 3. Provide exercise 4. Maintain/apply sequential compression device or anti-embolism stockings 5. Other appropriate intervention(s) • Document:  Education provided  Learner understanding of education provided  Assessment data of bilateral comparison of the most distal area of the assigned extremities: 1. Capillary refill 2. Color 3. Motor function 4. Sensation 5. Temperature Temperature 6. Pulse quality 7. Edema • Implement: 

©2018

Achieve

Page 27

of 53