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
