Clinical Assessment Preparation

CPNE Study Guide

6. Pulse location 7. Pulse quality 8. Edema

• Interventions implemented for peripheral neurovascular management • Patient response to interventions implemented Position patient to facilitate respiratory assessment • Perform assessment on bare skin • Position stethoscope over intercostal spaces • Instruct patient to breathe in and out slowly and deeply • Provide a receptacle to receive secretions as needed • Listen to the upper then lower, comparing side to side and top and bottom • Observe how the patient is managing their breathing • Assess:  Determine learner need(s) related to respiratory management  Determine respiratory status prior to hygiene interventions  Count respiratory rate  Observe respiratory depth  Observe respiratory rhythm  Observe respiratory effort  Measure oxygen saturation level to exact percentage 1. Observe oxygen delivery rate 2. Observe oxygen delivery method  Determine presence or absence of secretions • Implement:  Provide education based on learner needs  Perform respiratory hygiene interventions 

3.6 Respiratory Assessment •

Direct performance or perform respiratory hygiene intervention(s) based on patient’s current clinical condition 1. Deep breathing exercises 2. Coughing exercises 3. Direct patient to breathe in and out as deeply as possible 4. Direct patient to cough forcefully on third or fourth expiration 5. Direct patient to splint while coughing, if appropriate 6. Device exercises using the appropriate device for the amount of repetitions noted on the PCS Assignment (e.g., incentive spirometer, pin wheels, blowing bubbles)

• Provide oral care after hygiene activities

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