Clinical Assessment Preparation

CPNE Study Guide Range of motion Therapeutic devices Application of heat/cold Body alignment Positioning/activity  Patient response to interventions implemented     

3.10 Oxygen Management • Assess: 

Confirm oxygen delivery rate within the first 20 minutes after beginning the implementation phase • Determine learner need(s) related to oxygen management • Observe environment for safety • Assess integrity of surfaces affected by the oxygen delivery system:  Lips (e.g., dry, cracked, moist)  Mucous membranes (e.g., moist, dry, sticky)  Skin (e.g., color changes, chafing) • Determine oxygenation status by assessing:  Oxygen saturation level  Color of nail beds, lips, or mucous membranes  Respiratory effort  Respiratory changes associated with activity during PCS • Implement:  Provide education based on learner need(s)  Apply/maintain oxygen delivery device  Set/adjust/maintain oxygen flow at assigned rate (liters or percent)  Maintain humidification as assigned  Perform nursing intervention(s) to facilitate oxygenation  Perform nursing intervention(s) to prevent alterations/maintain integrity of surfaces  Safety checks (e.g., trip hazards, fire hazards) • Evaluate oxygen saturation level after interventions implemented • Evaluate patient response to interventions implemented • Document:  Education provided  Learner understanding of education provided  Condition of surfaces affected by oxygen delivery system  Oxygen delivery rate  Oxygen delivery method  Oxygen saturation level before interventions  Oxygen saturation level after interventions  Respiratory changes associated with activity during PCS  Nursing intervention to facilitate oxygenation implemented  Nursing interventions to prevent alterations/maintain integrity of surfaces  Patient response to interventions implemented

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