Clinical Assessment Preparation

CPNE Study Guide

Implemented during the PCS Age-appropriate

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Remember… •

 Interventions cannot be assessment related or collaborative for the CPNE! • Wording such as observe, inspect, monitor, weigh, measure, check, auscultate within an intervention indicates assessment. • Assessment interventions do not move the patient toward achieving their goal! • Collaborative interventions cannot be thoroughly evaluated during the PCS timeframe. Summary of the Development of a NCP: 1. Review the PCS Kardex, looking at the assigned selected areas of competencies being aware that this info will help to determine NDs and interventions 2. Review patient’s record collecting baseline assessment data r/t assigned areas of competencies 3. Request report from the nurse 4. Identify actual patient problems 5. Choose a ND from your Mosby’s book that represents the problems 6. Document the rationale for the selected nursing diagnosis 7. Identify and list expected patient outcome 8. Identify and list specific nursing interventions which move the patient toward the resolution of the problem using the “if…then” test Evaluation: Using your nursing judgment, evaluate the plan of care and document the following: • Two (2) assessment findings collected during implementation that validate the nursing diagnosis • Achievement of expected patient outcome by selecting either ‘Met’, ‘Not Met’ or ‘Partially Met’ • Write an evaluative statement regarding effectiveness of nursing interventions in meeting the expected patient outcome Promotion of teamwork through collaboration and delegation: Indicate a team member and care to be performed to assist in achievement of expected patient outcome. • Specify task/care to be performed (Example: Encourage patient to drink fluids hourly) • Identify team member (Example: Unlicensed assistive personnel) • This only needs to be documented on paper; you do not have to find the team member and delegate during the PCS. The CE simply wants to know to whom you would assign that task

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