Clinical Assessment Preparation

CPNE Study Guide

Other

•  Assess impaired/susceptible skin surfaces for: • Color changes (e.g., blanchable, non-blanchable, ethnic variations) • Edema • Integrity • Moisture level status (e.g., moist, dry) • Temperature (e.g., warm, hot, cool) • Turgor Provide education based on learner needs  Implement two nursing interventions to prevent alterations in skin integrity/maintain skin integrity based on patient’s current clinical condition, such as: • Reposition • Apply/maintain redistribution devices • Keep skin clean • Provide incontinence care • Apply protective products • Other appropriate intervention(s) • Document:  Education provided  Learner understanding of education provided  Total score on Braden Scale for Predicting Pressure Sore Risk  Assessment data for selected impaired/susceptible skin surfaces: • Location • Color changes (e.g., blanchable, non-blanchable, ethnic variations) • Edema • Integrity (e.g., altered, not altered) • Moisture level status (e.g., moist, dry) • Temperature (e.g. warm, hot, cool) • Turgor • Nursing interventions implemented to prevent alterations in skin integrity/maintain skin integrity • Patient response to interventions implemented • Implement: 

3.8 Comfort Management • Assess: 

Determine learner need(s) related to comfort  Determine comfort using one of the methods below: • Comfort Verbal Rating Scale • Comfort Daisies Scale • Observed behaviors indicative of discomfort  Establish patient preferences for addressing comfort needs

©2018

Achieve

Page 31

of 53