CPNE Flashcards
Fluid
Management
- Hydration: skin turgor
- Enteral: determine type fluid: encourage/restrict
- Parentral: fluid/rate, regulate,record
- Glove up: assess IV
- Calculate I/O
- When next solution or discontinue IV : check pt ID against Kardex & IV site
- Record parenteral if infused
- Record
20 minute check
Wash hands Intro/ID, explain, express, comfort Explain I/O (save tray/ toilet hat) Verify: fluid/rate. Feeding/rate Glove up: assess IV Record immediately
Andominal assessment
Pee, discomfort, turn off suction Position patient Inspect for distension Auscultate x4 on skin Palpate x4 for tenderness or rigidity Turn suction back on Record
Neurological assessment
Assess LOC: person,place,time
( under 3yr or non-verbal patient: visual, auditory, tactile stimuli)
Palpate anterior fontanel in upright position pt under 1 yr
Pupillary equality & reaction to light: dim lights
Motor response: hand grips simultaneously & dorsiflexion or plantar flexion of feet against resistance simultaneously
(Observe muscle movement &symmetry in pt under 3 yr or non-verbal pt)
Assess response noxious stimuli unconscious pt
Record
Peripheral Neurovascular Assessment
Palpate most distal pulses bilaterally
Compare most distal corresponding palpable pulses
Capillary refill: in multiple digits of both extremities
Tempature: of multiple digits of both extremities
Tactile stimuli: with eyes closed correctly identify multiple digits touched in both extremities
Motor function: move digits upon command ( observe movement in pt under 3 yr or non-verbal pt)
Record
Enter/leave room
Slippers Bed rails x2 Bed lowest setting Call bell in reach Phone in reach Remind I/O Wash hands
Respiratory Assessment
Position patient
Instructing pt to breath in and out slowly and deeply
Listen lung sounds x 4 on skin
Look at breathing pattern
Oxygen saturation when assigned
Record
Skin Assessment
Assess two vulnerable areas of skin:
Temperature Edema Moisture Integrity Color Record
Comfort Management
Assess comfort level or comfort needs (observe behaviors of discomfort)
Provide three comfort interventions
Reassess level comfort
Record
Musculoskeletal management
Presence of abnormalities
Level of movement
Pain with movement
Active ROM
Passive ROM
Supportive/therapeutic devices
Applies heat/cold therapy
Traction
Response
Record
Oxygen Management
Assess response to activity
Assess oxygen status: capillary refill or oxygen saturation if assigned
Assess skin in contact with tubing
Position pt to facilitate respirations
Oxygen rate
Equipment deliver oxygen
Humidify
Maintain Pulse ox on pt if assigned
Response to interventions
Record
Pain Management
Assess level of pain
Location pain
Quality pain
Duration pain
Provide three pain interventions
Reassess level of pain
Record
Respiratory Management
PILL
Deposit receptacle & tissues
Instruct to breath in and out
slowly &deeply
Instruct cough forcefully after three breaths ( splint device if necessary)
Was there expectoration of sputum
Incentive spirometer: instruct how use
Percussion: clap/vibrate
Suction
Reasses: PILL
Response
RECORD
Wound Management
Assess wound: location, type, appearance, presence/absent drainage, surrounding skin
Irrigate: solution, amount, temperature, system, receptacle, protect skin
Cleanse with designated solution
Topical preparation
Wound Packing
Wound protection: apply dressing(label)
Response
Record
Drainage and specimen collection
Assess amount & color drainage
Cleanse surrounding skin if assigned
Insert tube into appropriate body cavity
Remove tube
Drain via gravity with patent tube & container
Obtain specimen
Place in labeled container on designated surface
Place in designated area for transport
Rocord
Enteral Feeding
Selects prescribed feeding Determine amount Position pt Delivers feeding (Choose appropriate feeding device Burp infant under six months periodically)
Intermittant:
Selects prescribed feeding Determine amount Position pt Measure gastric residual/reinstill Initiate feeding within 30 minutes of scheduled time Regulate rate on pump Record
Continuous:
Verify feeding & rate against kardex
Measure gastric residual/ reinstill if assigned
Record
Record kind of feeding Record name & strength of feeding Record volume of gastric residual Record amount Record parenteral if infused
Irrigation/Instillation
Selects designated solution Determine amount Appropriate temp of solution Proper system Position pt facilitate irrigation Instill solution to designated area Position receptacle Protect skin Record type/amount
Intermittent venous access device :
Selects designated solution Determines amount ID patient against kardex Glove up/assess IV site Clean site Alcohol Aspirate Flush Record flush type/amount Record parenteral
Medication
Wash hands Selects medication using MAR Calculate dose/equipment/draw up Wash hands ID to MAR
SubQ/IM medications: Glove up Clean site alcohol Administer to pt within 30 minutes Apply pressure 2x2 Needle guard Record on MAR
IV medication: Glove up Assess IV Attach IVMB Clear air Initiate/regulate Record correct flow rate on PCS form (Record under parentral when infused) Record on MAR
Intermittent access device medication: Glove up assess IV Clean site alcohol Aspirate Flush prior & after medication delivery Record flush solution/amount PCSform Record flushes and med as parentral Record on MAR
Patient Teaching
Pt readiness to learn Assess motivation/ability to learn Identify barriers to learning Ask question determine learning needs Provide accurate information Determine understanding info provided Record
Mobility
level mobility Assistive devices Balance Movement: support weak extremities Support position Ambulation: maintain balance ( bed rest: can move freely/equally, can reposition self, support position,maintain proper alignment) Response Record
