Clinical Assessment Preparation

CPNE Study Guide

Implement: 

• Provide education based on learner needs  Provide two interventions from the list below based on patient’s unique needs • Use relaxation technique(s) • Use distraction technique(s) • Apply heat or cold when assigned • Adjust patient’s position • Swaddle infant • Provide pacifier • Provide comfort object • Other interventions consistent with patient’s current clinical condition  Reassess patient’s comfort with method used in assessment: • Comfort Verbal Rating Scale • Comfort Daisies Scale • Observed behaviors indicative of comfort • Document:  Education provided  Learner understanding of education provided  Comfort assessment method  Comfort assessment prior to intervention  Patient preferences for comfort needs  Comfort interventions implemented  Reassessment of comfort after interventions Appearance (e.g., atrophy, swelling, contractures, nodules, symmetry, condition of skin)  Muscle strength (e.g., flaccid, weak, strong)  Joint mobility (e.g., full range of motion, limited range of motion)  Symptom(s) with movement (e.g., pain, stiffness) • Determine fall risk using the Morse Fall Scale • Implement:  Provide education based on learner needs  Ensure/maintain proper body alignment throughout PCS  Implement fall prevention interventions consistent with patient’s current clinical condition: • Maintain bed/chair monitoring device • Reinforce with patient the need to use the call bell • Have patient demonstrate ability to call for nurse • Apply non-skid socks or shoes during ambulation or transferring activities • Other appropriate interventions  Perform range of motion exercises as assigned to the major joints of designated extremities based on patient’s current clinical condition 3.9 Musculoskeletal Management • Assess the assigned extremity for: 

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