Clinical Assessment Preparation

CPNE Study Guide

Chapter 6: CPNE Nursing Care Plans • Planning: The period of time before initiating care. Using nursing judgment, develop the initial plan of care based on patient’s current clinical condition and areas of competency, and document the following: • Includes the Assessment, Diagnosis, and Planning steps in the nursing process.  Assessments which are two pieces of patient data to support development of nursing diagnosis  One actual NANDA-I nursing diagnosis (may not use acute pain, chronic pain, or a readiness nursing diagnosis)  Rationale to support nursing diagnosis  One related factor (etiology) that contributes to nursing diagnosis   Two nursing interventions (may not use assessments) to be performed during the PCS to move patient toward achievement of the expected patient outcome  Rationale for each nursing intervention; explaining how each moves patient toward achievement of the expected patient outcome • Using your Mosby’s Guide:  Section I: Client symptoms, problems, medical and psychological conditions listed alphabetically  Based on your PCS, look in section I to determine which ND can be used for that symptom, problem, etc. • Example: Pneumonia (medical diagnosis) a nursing diagnoses would be- Ineffective airway clearance  Section II: Listing of ND • Find your nursing diagnosis listed alphabetically in Section II 1. Defining characteristics: Signs and symptoms a) This area needs to be thoroughly reviewed to ensure appropriateness of the ND b) Your patient should have at least one of these defining characteristics! 2. Related factors: Etiology or reason/cause for using the ND a) Do not just copy from the book!!! b) The related factor (or etiology) can never be a procedure, treatment, or person; however, the use of a medical diagnosis as the etiology is acceptable. • Example: Ineffective airway clearance r/t increased pulmonary secretions (in your assessment data you would have documentation that the patient had crackles at lung bases and increased sputum production 3. Client outcomes: CAUTION! Outcomes are listed globally; not specific and in measurable terms 4. Do not copy outcomes from the guide book without adapting it to your PCS and providing measurable terms: • Global terms: The patient will achieve maximum pulmonary function • Specific and measurable: The patient will have clear breath sounds in upper and lower lobes bilaterally Expected outcomes 1. Patient-centered 2. Measurable 3. Time limited (realistic date/time)

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