Clinical Assessment Preparation

CPNE Study Guide

Chapter 4: Assessments to complete within the First Twenty Minute Assessments (TMA) As you begin your PCS assignment there are assessments that when assigned to you must be completed within the first twenty minutes of the start of the PCS (Implementation Phase). Below are the Area of Competencies that require the student to complete the assessment of the critical elements within the first 20 minutes of implementation. Fluid Management if assigned on Kardex to be performed during the PCS: Remember to assess and document within 20 minutes of starting the Implementation Phase Continuous Enteral Feeding when assigned • Verify feeding formula infusing is same as noted on PCS Assignment Kardex • Assess current flow rate of infusion and verify it is the same as noted on PCS Assignment Kardex • Assess the Skin surrounding the entry site of tube feeding • Measure gastric residual unless contraindicated • Reinstall gastric residual when assigned • Assess patient’s response to feeding • Document findings on fluid management flow sheet Bolus Enteral Feeding when assigned • Assess integrity of tube feeding system • Assess the Skin surrounding the entry site of tube feeding • Measure gastric residual unless contraindicated • Reinstall gastric residual when assigned • Regulate flow rate to deliver volume of feeding as ordered • Ensure patient receives volume of feeding as ordered • Evaluate patient’s response to feeding • Document findings on fluid management flow sheet Parenteral Fluids when assigned • Assess insertion site for any color changes or presence of edema • Determine drops per minute for gravity flow • Verify flow rate is the same as noted on PCS Assignment Kardex • Adjust rate of flow if needed gravity flow or notify CE that rate needs adjusted on infusion control device and notify CE of what rate should be • Verify IV solution matches what is noted on PCS Assignment Kardex

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