Clinical Assessment Preparation

CPNE Study Guide

• • Respiratory rhythm Respiratory effort • Breath sounds in bilateral upper and lower lung fields • Oxygen saturation level to exact percentage • Oxygen delivery rate • Oxygen delivery method • Presence or absence of secretions • Respiratory hygiene intervention(s) implemented Evaluation after interventions: • Respiratory status •

Respiratory rate within established parameters of +/- 2 respirations/ minute for patients 2 years or older or +/- 6 respirations/minute for patients under 2 years • Respiratory depth • Respiratory rhythm • Respiratory effort • Breath sounds in bilateral upper and lower lung fields • Oxygen saturation level to exact percentage • Secretions:  Presence or absence  Amount  Color  Consistency  Odor, if present • Oral care provided • Patient response to interventions implemented Determine learner need(s) related to skin management  Predict accurate pressure ulcer risk using the Braden Scale for Predicting Pressure Sore Risk  Select one impaired/susceptible skin surface based upon the patient’s current clinical condition (bilateral comparison of symmetrical body parts is expected) • Ears • Elbows • Heels • Sacral/ Buttock area • Skin Folds • Trochanters

3.7 Skin Assessment • Assess: 

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