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CPNE Self-Check > Evidence Based (EBP) Tools > Flashcards

Evidence Based (EBP) Tools Flashcards

1
Q

What are the 3 “Comfort Management” assessment tools used during PCS?

A
  1. Comfort verbal rating scale (0-10).
  2. Comfort Daisies Scale (1-4) - used for non-verbal pt’s or young children.
  3. Observed behaviors indicative of comfort.
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2
Q

Regarding the comfort verbal scale, which number is the highest comfort possible and which number is no comfort at all?

A

10 is the highest comfort possible and 0 is no comfort at all.

  • this is the reverse of the pain numeric scale.
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3
Q

Regarding the comfort daisies scale, which number is the highest at “very good” and which number is the lowest at “very bad”?

A

Number 4 is the highest at “very good” and number 1 is the lowest at “very bad”.

*this is also the reverse of the numeric pain rating scale.

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4
Q

What are some examples of discomfort types?

A 
Itching, 
feeling too hot or cold, 
perspiration, 
wet hospital gown, 
bed too hard or soft, 
indigestion, 
pressure, 
humidity/dryness, 
light too bright or dim, 
too much noise, 
fatigue, 
loneliness, 
grief, 
cultural unfamiliarity, 
sleep deprivation.
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5
Q

What are the 3 components of comfort management?

A

1) assessment of the comfort.
2) Interventions to alleviate discomfort and increase comfort.
3) Reassessment of comfort to determine whether interventions were effective.

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6
Q

What does the acronym “AIR” stand for and which assessment tool is it used?

A

“AIR” stands for:

Assessment
Interventions
Reassessment

Used for Comfort AOC.

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7
Q

Regarding the AOC Comfort Management, what are some interventions you can do during the PCS?

A

Some Interventions for comfort:

Use relaxation techniques.
Use distraction techniques.
Apply heat or cold pack (if ordered by health care provider).
Adjust the pt's position.
Swaddle an infant.
Provide pacifier to infant.
Provide a comfort object (e.g. Toy, pillow).
Change environment temperature.
Offer massage (e.g. Back, hand, foot).
Change bed linens or gown.
Place cool washcloth on face.
Other interventions consistent with pt's current clinical condition.
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8
Q

For Comfort management AOC, you must do what verbal critical element with pt? What are some examples?

A

For Comfort Management AOC, you must
“EDUCATE THE PATIENT” and provide education based on learners needs about comfort.

Some example are:

1) instruction on how bed controls work to adjust head of bed when the head of bed is a discomfort.
2) Demonstrating how to adjust the over bed light or TV sound to make them more comfortable - when light or noise is the source of discomfort.
3) teach the pt about prescribed medications improve comfort.

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9
Q

What are the 3 “Pain EBP Assessment Tools”?

Which AOC’s is the pain assessment used as part of the critical elements?

A
  1. FLACC Pain Rating Scale (2 months to 3 years).
  2. FACES Pain Rating Scale (3 years and older).
  3. Numeric Rating Scale.
  • Use to reassess following Nursing interventions.

Pain scale is used in AOC critical elements:

Abdominal Assessment.
Musculoskeletal Management.
Vital Signs.
Wound Management.

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10
Q

What is the FLACC Pain Rating Scale categories?

What ages is it appropriate for and when is it used?

A

“FLACC” -
5 categories scored 0-2 (0 being normal and 2 agitated).

F - Face
L - Legs
A - Activity 
C - Cry
C - Consolability

Appropriate for ages 2 months - 3 yrs

Used when child cannot provide self information.

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11
Q

How is the FACES Pain Rating Scale used and what ages?

A

“FACES Pain Rating Scale” -

Scored 0-5
(with 0 “very happy” with no pain and 5 “hurts as much as you can imagine”)
- self report tool.

  • ask pt to choose face that describes current feeling.
  • ages 3 years and older.
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12
Q

What is the “Numeric Rating Pain Scale”?

A

Uses 0-10 with 0 no pain, 5 moderate pain, and 10 worst pain possible.

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13
Q

What is the Braden Scale used for and which AOC is it a critical element?

A

The Braden Scale for Predicting Pressure Score Risk is a tool used during CPNE to identify pt’s at risk for developing pressure ulcers.

Uses as ulcer risk assessment, prevention interventions, and documentation as part of the Critical Elements in AOC -

Skin Management!

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14
Q

How is the Braden Scale for developing pressure ulcers rated?

A

Items Scored: 6 categories -

  1. Sensory
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction and Shear.

A total score of 18 or less is considered a RISK for pressure ulcer development.

The lower the score the higher the risk.

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15
Q

Regarding the Braden Scale what would be some interventions for a 92 y/o admitted to the hospital 2 days ago for urosepsis, hx of dementia, on bedrest, unable to walk or change position independently, refused breakfast but ate lunch with only small sips of juice consumed, and has contracted extremities with a dry bed/gown?

A

Some examples of interventions would be:

Gently apply moisturizing lotion.
Provide frequent turns.
Maintain specialty mattress.
Encourage oral fluids.

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16
Q

What is the Morse Fall Scale EBP assessment tool used for?

Which AOC is it used as a Critical Element?

A

The Morse Fall Scale is used to identify pt’s at risk for falls during the CPNE.

Fall risk assessment, and prevention interventions are part of the Critical Elements in -

Musculoskeletal Management.

17
Q

How is the Morse Fall Scale scored and utilized during the PCS?

A

Six items scored.

  • use pt centered information section on PCS assignment with other data collected to score each item.
  • the sum of each item score indicates risk level.
  • DOCUMENTATION Critical Elements include the Morse Fall Scale Score and Risk Level.
18
Q

What are the 6 categories scored on the Morse Fall Scale?

A
  1. Hx of falling; immediate or within 3 months.
  2. Secondary diagnosis.
  3. Ambulatory Aid -

bed rest/nurse assist
crutches/cane/walker
furniture.

  1. IV/Heparin Lock.
  2. Gait/Transferring -

Normal/bed rest/immobile
Weak
Impaired.

  1. Mental Status -

Oriented to own ability
Forgets limitations.

19
Q

What are the Risk Levels for the Morse Fall Scale?

A

0-24 No Risk; use good basic nursing care.

25-50 Low Risk; Implement standard fall prevention interventions.

> =51 High Risk; Implement high risk fall prevention interventions.

20
Q

Regarding the Morse Fall Scale, what would be some interventions for a 78 y/o pt with admission diagnosis of syncope, fell at home yesterday, hx of type 2 diabetes, IV infusing, takes several attempts to get her up from the chair, & she know she must use her call light if she needs to get out of bed.

A

Some interventions would be:

Apply non-skid socks when transferring pt.
Keep floors free of clutter.
Provide hourly rounding.

CPNE Self-Check (6 decks)

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