iv Study Guide for the Clinical Performance in

Transcription

14th Edition, 1st Printing
July 2007
EX: 0418
14th Edition
First Printing
July 2007
ISBN 1-889403-72-5
ËxHSLISJy403724zv&:!:+:+:!
“No part of this publication may be reproduced or
distributed in any form or by any means, or stored in
a database or retrieval system, without the prior written
permission of the Dean of the School of Nursing.”
Copyright ©2007 by Excelsior College.
“Excelsior College” and “CPNE” are registered
servicemarks of Excelsior College.
All rights reserved.
Printed in the United States of America.
Excelsior College does not discriminate on the basis of age, color, religion, creed, disability, marital status, veteran status, national origin, race, gender, or sexual orientation in the educational programs and activities which it operates. Portions of this publication can be made available in a variety
of formats upon request. Inquiries should be directed to the Affirmative Action Officer, Excelsior College, 7 Columbia Circle, Albany, NY 12203.
The CPNE® is held at a location that is accessible to individuals with disabilities. If you will need auxiliary aids or services, please contact a CPNE Nurse
Faculty at 518-464-8500 or toll free at 888-647-2388 (TDD: 518-464-8501). At the automated greeting, press 1-3-1-2 for information or assistance.
iii
CPNE Study Guide 14th Edition
Summary of Changes
Critical Elements as listed in the 14th edition of the CPNE Study Guide will be in
effect starting the weekend of October 5, 2007 through September 30, 2008. In the
14th edition of the study guide you will find the following specific changes.
Areas of Care
nS
kin Assessment
The ulcer risk assessment (Braden Scale) has been eliminated. The Critical
Elements for Skin Assessment are as follows:
Skin Assessment: The assessment of vulnerable skin surfaces for
adults and children.
The successful student:
1.Assesses, from the list below, a minimum of two vulnerable skin surfaces
including any designated area(s) for:
a. color changes
b. integrity (e.g., lesions, rash, sheer and pressure effects, skin tears)
c. temperature
d. edema
e.moisture (e.g., perspiration, incontinence, diarrhea,
non intact ostomy/drainage system)
heels
sacral/coccyx
occiput
trochanter
skinfolds
peri anal
designated area
2.Records assessment data of two vulnerable skin surfaces including any
designated area(s) related to
14th Edition, July 2007
a. color changes
c. temperature
d. edema
e.moisture (e.g., perspiration, incontinence, diarrhea,
Copyright©2007 by Excelsior College. All rights reserved.
iv
Study Guide for the Clinical Performance in Nursing Examination
nP
ain Management:
The FLACC behavior pain assessment scale has been added for use with the child
2months to 3 years of age. The assessment Critical Elements for Pain Management
are as follows:
1. Assesses the patient’s level of pain by:
a.Asking an adult to rate level of pain using a 0 –10 scale or a
visual analog scale
b.Asking a child, 3 years of age or older, to rate level of pain using
a 0 –5 faces scale
OR
c.Using the FLACC pain assessment tool to rate level of pain for
a child ranging in age 2 months to 3 years of age.
OR
OR
d.Observing behaviors indicative of pain in a patient unable to rate
his or her pain (e.g., moaning, grimacing, clutching, restlessness)
nE
valuation:
A new critical element has been added to reflect the requirement of writing a
measurable expected outcome. The second Critical Element of the Evaluation
Phase is as follows:
2. Selects one priority nursing diagnostic label
a. Writes a related factor (etiology) for the selected nursing diagnosis
b.Writes the signs and symptoms (defining characteristics) for the selected
nursing diagnosis, if an actual problem
c. Writes a measurable expected outcome
d.Justifies the importance of choosing this as the priority nursing diagnosis
v
Clinical Performance in Nursing Examination Subcommittee and Nurse Faculty
Sharon A. Aronovitch, PhD, APRN, BC, CWOCN (Adelphi University, New York, NY,
Career Mobility in Nursing, 1995), Nurse Faculty, School of Nursing, Excelsior College
Elizabeth A. Ayello, PhD, RN, CSC, WOCN (New York University, Nursing Theory and
Research, 1994), Clinical Assistant Professor of Nursing, New York University
Jean Colaneri, MS, RN, CNN (Russell Sage College, Acute Care Nurse Practitioner, 2005)
Clinical Nurse Specialist, Albany Medical Center
Ivory Coleman, PhD, RN (Pennsylvania State University, Higher Education, 2004),
Professor, Community College of Philadelphia
Kathie Doyle, MS, RN (Russell Sage College, Medical Surgical Clinical Nurse Specialty,
1981), Nurse Faculty, School of Nursing, Excelsior College
Glenda B. Kelman, PhD, RN, ACNP, CS, OCN (New York University, Nursing Theory and
Research, 1997), Program Chair, The Sage Colleges
Ellen M. LaDieu, MS, RN (Russell Sage College, Community Health, 1989), Nurse Faculty,
School of Nursing, Excelsior College
Patricia Mahoney, MS, RN (Seton Hall University, Adult Health, 1983), Nurse Faculty,
School of Nursing, Excelsior College
M. Bridget Nettleton, PhD, RN (University at Albany, State University of New York,
Educational Administration and Policy Studies, 1996) Dean, School of Nursing,
Excelsior College
Dicey O’Malley, PhD, RN (State University of New York, Albany Program Development
and Evaluation, 1984) Chair, Nursing Department, Hudson Valley Community
Community College, Troy, NY
Bonita Page, MS, RN (State University of New York at Cortland, Health Education, 1972,
State University of New York at Binghamton, Family Nurse Clinical Specialist, 1985),
Nurse Faculty, School of Nursing, Excelsior College
Barbara Smith, MS, RN (Russell Sage College, Medical-Surgical Nursing/Education,
1980), Nurse Educator, VA Health Care Network Upstate New York at Albany
Kathleen Quaile, MS, RNC, CS (State University of New York, New Paltz, Family Health
Nursing, 2000) Nurse Faculty, School of Nursing, Excelsior College
Helene Wallingford, MS, RNC (The Sage Colleges, Parent/Child Nursing, 1992),
Nurse Faculty, School of Nursing, Excelsior College
Suzanne Yarbrough, PhD, RN (Texas Woman’s University, Houston Center, Houston,
Texas, 1994, Nursing) Associate Dean, School of Nursing, Excelsior College
vi
Contact List
Staff Members
Contact Information
Questions Related To:
Excelsior College
School of Nursing
7 Columbia Circle
Albany, NY 12203-5159
Main telephone: 518-464-8500
8:30 a.m. – 5 p.m. ET
Toll free: 888-647-2388
TDD: 518-464-8501
Fax: 518-464-8777
Associate degree nursing
programs, CPNE Office
ress 1-3-1-2 over the recording
P
Email: [email protected]
• Scheduling the CPNE in NPAC
• CPNE preparation questions
• General questions related to
the CPNE
Midwestern Performance
Assessment Center (MPAC)
Phone: 800-439-6527
• Scheduling the CPNE in MPAC
Southern Performance
Assessment Center (SPAC)
Phone: 404-325-5536 ext. 101
• Scheduling the CPNE in SPAC
Academic Advisor
Press 1-3-1-4 over the recording
• theory examination test scores
• status reports
• CPNE eligibility
• academic fees
• general degree program planning
State Board Advisor
Press 1-3-1-5 over the recording
• completing applications for State
Board (NCLEX) examinations after
you complete the CPNE
Associate degree nursing
programs, LEARN Office
ress 1-3-1-6 over the recording
P
• scheduling and attending
a CPNE workshop or
• registering for an
online conference
Electronic Peer Network
E mail: with general questions
[email protected]
for technical support
[email protected]
Phone: Press 1-4-4 over the recording
or dial 518-464-8577
• Nursing Chats and Lounges
Web: Go to www.excelsior.edu, login,
and click on the Electronic Peer
Network link on your MyEC page.
Excelsior College Virtual Library
www.excelsior.edu/library
Phone toll free: 877-247-3097
Excelsior College Bookstore
c/o MBS Direct
Phone: 800-325-3252
Fax: 800-325-4147
Web: www.excelsior.edu/bookstore
Excelsior College World
Wide Web Address
www.excelsior.edu
• You can send us a fax at any time, day or night. You must always address your fax to
a specific office or staff member.
Note
• When you place a call, be sure to have your Student Identification number avail-
able to that we can quickly access your student record. Please provide your Student
Identification number on all written and electronic correspondence.
vii
Welcome
Welcome to the Clinical Performance in Nursing Examination (CPNE) Study Guide.
Whether you practice in a multi-disciplinary inpatient setting, skilled nursing facility
or other health care settings, mastering the knowledge and skills outlined in this
study guide is essential to your success as a Registered Nurse (RN). This study guide
describes what a “performance examination” is, the nursing content tested in the
CPNE, and how performance is evaluated. The study guide also offers suggestions for
developing an effective study plan and determining when you are ready to schedule
your examination appointment.
The study guide is formatted to help you find the information you need. It is designed
to guide learning in three areas: self-directed college-level learning at a distance,
preparation for performance assessment, and learning the structure, process, and
content of the CPNE.
The College’s nursing faculty believes that learning occurs within the individual and
that as an adult learner you can best determine your own learning needs. We hope
you are beginning this self-study process with a positive attitude, ready to take charge
of your learning, add depth to your current knowledge and clinical competence, and
ultimately meet your career goals. Over 33,000 Excelsior College nursing graduates
have proven that a nursing degree can be earned using the Excelsior College distance
education model.
We encourage you to stay in contact with us as you prepare for the CPNE. The
preceding page lists contact information. We expect that you will have questions
and we want to help you find answers that can guide you through the process of
preparation.
We hope you find this CPNE Study Guide helpful and that you also find it clearly
defines what is expected of you.
Best wishes,
The CPNE Subcommittee Faculty and the Associate Degree Nursing Faculty
viii
Contents
CPNE Study Guide 14th Edition ............................... iii
Summary of Changes...................................... iii
Areas of Care............................................... iii
Clinical Performance in Nursing
Examination Subcommittee and
Nurse Faculty.................................................... v
Welcome....................................................................vii
Unit I: Introduction...................................................... I
Overview................................................................ I.A.1
The Clinical Performance in
Nursing Examination..................................I.A.1
Excelsior College Philosophy of Nursing
and Nursing Practice...................................I.A.1
Standards of professional nursing
practice guide your performance
in the CPNE..................................................I.A.2
A Code for Nursing Students......................I.A.3
Nursing process used in the CPNE.............I.A.4
CPNE Objectives..........................................I.A.5
Evaluation of Your Clinical Performance ..I.A.5
Associate Degree Nursing Learning Resources.....I.B.1
Features of the CPNE Study Guide............. I.B.1
CPNE Individual Advisement Calls............. I.B.2
CPNE Information Mail Box........................ I.B.2
Online CPNE Chat........................................ I.B.2
Resources Available from
the LEARN Team......................................... I.B.2
Online Conferences..................................... I.B.3
CPNE Online Conference—
Beginning CPNE Preparation.................. I.B.3
CPNE Online Conference—Nursing
Care Planning (NUR 3010)...................... I.B.3
Documentation (500 Y)........................... I.B.3
Skills (500 S)............................................ I.B.3
Workshops................................................... I.B.4
CPNE Workshop...................................... I.B.4
ix
Additional Resources.................................. I.B.4
CPNE Video (VHS or DVD)
and interactive workbook...................... I.B.4
CPNE Skills Bag....................................... I.B.4
CPNE Flash Cards/CD............................. I.B.4
Professional Learning Resources.......................... I.C.1
Books, Journals, and Web sites.................. I.C.1
References................................................... I.C.2
A. Nursing Theory and
Clinical Decision Making........................ I.C.2
Planning Phase........................................ I.C.2
B. Clinical Practice Techniques
and Procedures....................................... I.C.2
Asepsis..................................................... I.C.3
Caring...................................................... I.C.3
Drainage and Specimen Collection........ I.C.3
Enteral Feeding....................................... I.C.4
Fluid Management.................................. I.C.4
Medications............................................. I.C.5
Musculoskeletal Management .............. I.C.5
Pain Management................................... I.C.6
Peripheral Vascular Assessment............ I.C.6
Respiratory Assessment.......................... I.C.7
Skin Assessment..................................... I.C.7
Vital Signs................................................ I.C.7
Wound Management............................... I.C.7
C. Communication and Culture.............. I.C.8
Women’s Health.gov............................... I.C.8
D. Ethics and Legal Aspects................... I.C.8
Code of Ethics for Nursing
with Interpretive Statements.................. I.C.9
E. Background Nursing Content............. I.C.9
F. Test Taking and Stress Management.I.C.9
Internet Resources.................................. I.C.9
Resources Available through Excelsior College ...I.D.1
Available for Purchase through
Excelsior College Bookstore.......................I.D.1
Online Library Services...............................I.D.2
Excelsior College Electronic
Peer Network (EPN).....................................I.D.2
Excelsior College Graduate
Resource Network (GRN)............................I.D.2
Unit II: Structure, Process,
and Application Policies............................................. II
CPNE Structure . ..................................................II.A.1
CPNE Administration..................................II.A.1
Travel Information......................................II.A.1
x
Standards of professional dress
required for the CPNE................................II.A.3
Cancelling/Postponing
Examination Date.......................................II.C.4
Test Site......................................................II.A.4
Changing my CPNE Date...........................II.C.4
CPNE Nursing Faculty Roles......................II.A.4
Transfer Policy............................................II.C.4
Clinical Associate.......................................II.A.5
Additional Study Guide Policy...................II.C.4
Clinical Examiner.......................................II.A.6
Emergencies...............................................II.C.5
Clinical Associate and
Clinical Examiner Qualifications...............II.A.7
Accommodation for Disabilities................II.C.5
CertifiedBackground.com..........................II.C.7
Maintaining objectivity during
CPNE Administration..................................II.A.7
Unit III: Preparing for the CPNE................................ III
Expected Student Behaviors......................II.A.8
Learning Readiness.............................................III.A.1
Student Orientation....................................II.A.9
CPNE Schedule.........................................II.A.10
PCS Rotation.............................................II.A.10
CPNE Process.......................................................II.B.1
Preparation................................................III.A.1
Learning Strategies............................................ III.B.1
Know the Study Guide..............................III.B.1
Practice, Practice, and Practice.................III.B.1
Simulation Laboratory...............................II.B.1
Scope of Practice.......................................III.B.1
Simulation Laboratory Orientation...........II.B.1
Evaluate your current knowledge............III.B.2
Completing the Simulation Laboratory.....II.B.2
Study each Area of Care in depth............III.B.2
PCS Framework..........................................II.B.3
Study the references.................................III.B.2
Orientation to the Patient Care Unit.........II.B.4
Equipment Orientation...............................II.B.4
Integrate your study into your
clinical practice.........................................III.B.3
The PCS Assignment..................................II.B.5
Develop Nursing Care Plans (NCP)...........III.B.3
Assigned Areas of Care..............................II.B.5
Create a mock situation............................III.B.4
Criteria for Patient Selection......................II.B.6
Don’t try to do everything at once...........III.B.4
Criteria for changing the
patient assignment.....................................II.B.7
Picture yourself as successful...................III.B.4
The Planning Phase....................................II.B.7
The Implementation Phase........................II.B.7
The Evaluation Phase.................................II.B.9
Passing the CPNE.....................................II.B.10
Failing the CPNE.......................................II.B.10
Appeal Process.........................................II.B.11
“Uphold Failure”.......................................II.B.12
“Repeat Without Fee Without Penalty”....II.B.12
“Reverse to Pass”......................................II.B.12
Application Policies..............................................II.C.1
Managing Stress..................................................III.C.1
Four Common Stressors...........................III.C.1
Impact of Stress on Performance.............III.C.4
Gaining Information..................................III.C.5
Develop a plan of action......................III.C.5
Develop a skill set.................................III.C.5
Decrease the unknowns.......................III.C.5
Interventions for Stress Reduction.......III.C.5
CPNE Last Minute Checklist......................III.C.8
Packing for Travel.................................III.C.8
On Arrival at the Hotel/Motel..............III.C.8
The Evening Before the Examination..III.C.8
The Morning of the Examination.........III.C.8
Eligibility.....................................................II.C.1
Costs associated with taking the CPNE....II.C.1
Application Process....................................II.C.1
Health Status Report..................................II.C.2
Confirming CPNE Date...............................II.C.3
Unit IV: Critical Elements.......................................... IV
Organizational Content...................................IV
Suggestions for Study.....................................IV
The Planning Phase............................................ IV.A.1
Overview of the Planning Phase..............IV.A.1
How to Use Your Nursing
Diagnostic Guide/Handbook....................IV.A.2
xi
Physical Jeopardy............................................. IV.D.5.a
Critical Thinking Answer Key................IV.D.5.d
Required Areas of Care.......................................... IV.E
Critical Elements for Fluid Management.......... IV.E.1.a
Critical Thinking Answer Key................IV.E.1.q
Critical Elements for Vital Signs....................... IV.E.2.a
Differences Between the Carpenito-Moyet’s
Handbook of Nursing Diagnosis and the
Requirements of the CPNE........................IV.A.3
Selected Areas of Care Related to Assessment....... IV.F
A Nursing Care Plan Case Example.........IV.A.6
Abdominal Assessment......................................IV.F.1.a
Writing Nursing Interventions..................IV.A.9
Steps to Develop a Nursing Care Plan...IV.A.10
Criteria for Acceptance of the
Nursing Care Plan....................................IV.A.13
Critical Thinking Answer Key.................IV.A.21
Implementation Phase........................................ IV.B.1
Implementing your Nursing Care Plan.....IV.B.1
Timed Critical Elements............................IV.B.2
Clinical Decision Making (CDM)......................... IV.C.1
Critical Thinking Answer Key................ IV.E.2.g
Critical Elements for
Abdominal Assessment......................... IV.F.1.a
Critical Thinking Answer Key.................IV.F.1.e
Neurological Assessment . ................................IV.F.2.a
Neurological Assessment....................... IV.F.2.a
Critical Thinking Answer Key................ IV.F.2.g
Peripheral Vascular Assessment........................IV.F.3.a
Definition...................................................IV.C.1
Peripheral Vascular Assessment........... IV.F.3.a
Utilizing CDM............................................IV.C.1
Critical Thinking Answer Key................ IV.F.3.g
Case Study.................................................IV.C.2
Evaluating CDM.........................................IV.C.2
Overriding Areas of Care........................................IV.D
Asepsis.............................................................. IV.D.1.a
Critical Elements for Asepsis.................IV.D.1.a
Latex Allergy...........................................IV.D.1.b
Critical Thinking Answer Key.................IV.D.1.f
Caring............................................................... IV.D.2.a
Critical Elements for Caring...................IV.D.2.a
Emotional Jeopardy.......................................... IV.D.3.a
Critical Thinking Answer Key................IV.D.3.c
Mobility............................................................. IV.D.4.a
Critical Elements for Mobility................IV.D.4.a
Respiratory Assessment.....................................IV.F.4.a
Respiratory Assessment......................... IV.F.4.a
Skin Assessment................................................IV.F.5.a
Skin Assessment.................................... IV.F.5.a
Selected Areas of Care
Related to Management.........................................IV.G
Comfort Management.......................................IV.G.1.a
Comfort Management ...........................IV.G.1.a
Critical Thinking Answer Key................IV.G.1.e
Musculoskeletal Management..........................IV.G.2.a
Musculoskeletal Management...............IV.G.2.a
Critical Thinking Answer Key............... IV.G.2.h
xii
Oxygen Management.......................................IV.G.3.a
Evaluation Phase.................................................. IV.I.1
Oxygen Management.............................IV.G.3.a
Critical Elements for the
Evaluation Phase........................................ IV.I.1
Critical Thinking Answer Key................ IV.G.3.f
Critical Thinking Answer Key.................. IV.I.34
Pain Management............................................IV.G.4.a
Pain Management..................................IV.G.4.a
Critical Thinking Answer Key................ IV.G.4.f
Respiratory Management.................................IV.G.5.a
Respiratory Management.......................IV.G.5.a
Critical Thinking Answer Key.................IV.G.5.j
Wound Management........................................IV.G.6.a
Wound Management..............................IV.G.6.a
Critical Thinking Answer Key................IV.G.6.e
Other Selected Areas of Care.................................IV.H
Drainage and Specimen Collection.................. IV.H.1.a
Drainage and Specimen Collection.......IV.H.1.a
Critical Thinking Answer Key............... IV.H.1.d
Enteral Feeding................................................ IV.H.2.a
Critical Elements for Enteral Feeding....IV.H.2.a
Critical Thinking Answer Key.................IV.H.2.i
Irrigation.......................................................... IV.H.3.a
Simulation Laboratory Stations............................... IV.J
Wound Management......................................... IV.J.1.a
Wound Management............................... IV.J.1.a
Critical Thinking Answer Key................. IV.J.1.h
Intravenous Medication..................................... IV.J.2.a
Intravenous Medications........................ IV.J.2.a
IV Push Medication........................................... IV.J.3.a
Injectable IV Push Medications.............. IV.J.3.a
Injectable Medication:
Intramuscular or Subcutaneous........................ IV.J.4.a
Critical Elements for Injectable Medication:
Intramuscular or Subcutaneous............. IV.J.4.a
Critical Thinking Answer Key................. IV.J.4.g
Appendix Listing.................................................. App.1
Appendix A: CPNE Definitions..........................App.A.1
Critical Elements for Irrigation..............IV.H.3.a
Appendix B: Regional Performance
Assessment Centers..........................................App.B.1
Critical Thinking Answer Key............... IV.H.3.d
Appendix C: Academic Honesty .......................App.C.1
Medications...................................................... IV.H.4.a
Critical Elements for Medications.........IV.H.4.a
Critical Thinking Answer Key.................IV.H.4.l
Patient Teaching............................................... IV.H.5.a
Patient Teaching.....................................IV.H.5.a
Critical Thinking Answer Key............... IV.H.5.h
Appendix D: CPNE Student Orientation.......... App.D.1
Appendix E: Universal Time Chart................... App.E.1
Appendix F: Simulation Laboratory
Orientation Guide 2007................................... App.F.1
Appendix G: CPNE Simulation
Laboratory Report........................................... App.G.1
Appendix H: Blank Student
PCS Response Form........................................ App.H.1
xiii
Appendix I: Study Plan Time Analysis............... App.I.1
Appendix J: Self Assessment for the CPNE........ App.J.1
Appendix K: Patient Care Situation (PCS)
Scoring Tool.....................................................App.K.1
Appendix L: Excelsior College
Statement on Standard Precautions
for Infection Control......................................... App.L.1
Appendix M: Reasonable Accommodations
for Students with Disabilities.......................... App.M.1
Appendix N: Approved and
Unacceptable Abbreviations ............................App.N.1
Approved Abbreviations
for the CPNE.......................................... App.N.1
Unacceptable Abbreviations
for the CPNE.......................................... App.N.2
Appendix O: Additional Practice Care Plans... App.O.1
Appendix P: State Board Application Process.. App.P.1
NCLEX-RN® Application and
Graduation Processing Timeline........... App.P.2
Frequently Asked Questions.................. App.P.3
Index
Limitations
Information in this Study Guide is current as of June 2007, and is subject to change
without advance notice.
Changes in College Policies, Procedures, and Requirements
The College reserves the right to modify or revise the admission requirements to any program
of the College; degree and graduation requirements; examinations, courses, tuition, and fees;
and other academic policies, procedures, and requirements. Generally, program modifications
and revisions will not apply to currently enrolled students so long as they actively pursue their
degree requirements. However, in the event that it is necessary to make program changes
for enrolled students, every effort will be made to give notice. It is also the responsibility of
students to keep themselves informed of the content of all notices concerning such changes.
Accreditation
Excelsior College is accredited by the Commission on Higher Education of the Middle States
Association of Colleges and Schools, 3624 Market Street, Philadelphia, PA 19104, 215-6625606. The Commission on Higher Education is an institutional accrediting agency recognized
by the U.S. Secretary of Education and the Council for Higher Education Accreditation (CHEA).
The associate, baccalaureate, and master’s degree programs in nursing are accredited by the
National League for Nursing Accrediting Commission (NLNAC), 61 Broadway, New York, NY
10006, 800-669-1656. The baccalaureate degree programs in electronics engineering technology and nuclear engineering technology are accredited by the Technology Accreditation
Commission (TAC) of the Accreditation Board for Engineering and Technology (ABET), 111
Market Place, Suite 1050, Baltimore, MD 21202, 410-347-7700. The NLNAC and TAC of ABET are
specialized accrediting agencies recognized by the U.S. Secretary of Education. The Master of
Arts in Liberal Studies program has been accepted into full membership by the Association of
Graduate Liberal Studies Programs. This constitutes accreditation in the field of graduate liberal
studies. All the College's academic programs are registered (i.e., approved) by the
New York State Education Department.
Excelsior College Examinations are recognized by the American Council on Education (ACE),
Center for Adult Learning and Educational Credentials, for the award of college-level credit.
Excelsior College Examinations in nursing are the only nursing exams approved by ACE.
Drug-Free Workplace and School
Excelsior College maintains a drug-free workplace. In addition, Excelsior College is a drug-free
school, as provided by the Federal Drug-Free Schools and Communities Act of 1989.
xiv
I
Unit I: Introduction
Section A:
Overview
Section B:Excelsior College Associate Degree Nursing
Learning Resources
Section C:
Professional Learning Resources
Section D:
Excelsior College Resources
I.A.1
UNIT I
Section A
Overview
The Clinical Performance in Nursing Examination
The Clinical Performance in Nursing Examination (CPNE) is an eight credit-hour
criterion-referenced performance examination that tests your ability to care for adults
and children with common health problems. The examination is administered in an
acute care setting. Through observation of the decisions you make in the clinical
setting and your performance of the required behaviors (referred to as Critical
Elements), an expert in the field of nursing will determine your competence to
perform the required areas of nursing care.
Clinical performance is assessed through Patient Care Situations (PCSs) conducted
on medical-surgical and pediatric units in a hospital as well as through Simulation
Laboratories conducted in a classroom setting using models and mannequins.
You will provide care for patients who are experiencing potential, actual, or
recurring health problems requiring maintenance and restorative interventions.
The examination is administered over 2-½ consecutive days at an Excelsior
College test site.
Since the CPNE is the only clinical performance examination in the Associate
Degree nursing program, successful completion of the CPNE is required of all
nursing students graduating from the program.
Excelsior College Philosophy of Nursing and Nursing Practice
Philosophy
The School of Nursing community believes that nursing is a scientific discipline with
a distinct body of knowledge. Nursing uses this knowledge along with knowledge
from other disciplines to shape and inform practice. Nurses engage with people in a
dynamic partnership and come to know them as holistic beings. The nurse-person
relationship reflects dignity, valuing, and respect for personhood. The focus of nursing
is with individuals, families, aggregates, communities, and systems. Health is the
actualization of human potential and is manifested uniquely in multidimensional and
dynamic patterns and processes across the lifespan in response to changes in the
environment. Environment, both external and internal, provides the context within
which nurse-person interaction and health occur. These paradigmatic beliefs guide
nursing practice and underpin nursing knowledge development and discovery.
The faculty is committed to an educational philosophy that emphasizes competency
assessment and learning at a distance. The faculty supports programs that are
designed to meet the educational goals of a diverse population of adult learners
I.A.2
who bring varied lifelong knowledge and experience to the learning encounter.
The faculty views adult independent learning as a process of knowledge acquisition
attained through exposure to varied planned educational strategies unconstrained
by time and/or place. The faculty believes that curricula are best designed using
consensus-building by a national faculty of content experts, master educators, and
clinicians who make curricular decisions based on principles of adult learning,
internally generated data, and evidence of best practice in nursing education.
The faculty believes that knowledge related to adult learning and assessment of
competence can be applied to support the concepts of both external and distance
nursing education.
The faculty is responsible for determining what must be learned; how learning can
be supported; and how learning is assessed. The faculty believes that adult learners
have the capacity to create their own learning experiences guided by each program’s
curricular framework. The ability to learn, readiness to learn, motivation to learn, and
responsibility to learn are seen as characteristics of the adult learner rather than of
the faculty or the educational institution providing the degree.
The faculty believes that society’s healthcare needs can be served by nurses with
different levels of education. Therefore, the Excelsior College School of Nursing
offers associate, baccalaureate, and master’s degree programs and learners have
the opportunity to seek the educational level most suited to their needs and prior
preparation.
Standards of professional nursing practice guide your
performance in the CPNE
The American Nurses Association (ANA) Standards of Clinical Nursing Practice,
ANA Code of Ethics for Nurses, and International Council of Nurses (ICN) Code of
Ethics for Nurses are national and international standards used to guide nursing
practice. Standards of professional nursing practice from various specialized nursing
organizations can also be used to guide your practice. During the CPNE, it is expected
that you safeguard the privacy of patients by protecting information of a confidential
nature. Adherence to HIPAA guidelines and requirements are expected during the
CPNE. You will be asked to sign a confidentiality agreement when you submit your
CPNE application.
The National Student Nurses Association (NSNA) recognizes the need for guidance
as student nurses develop. The following Code of Academic and Clinical conduct
provides a foundation for ethical conduct both in academic and clinical settings.
The NSNA invites you to adhere to the following ethical principles.
Overview
I.A.3
A Code for Nursing Students
As students are involved in the clinical and academic environments we believe that
ethical principles are a necessary guide to professional development. Therefore,
within these environments we:
1. Advocate for the rights of all clients.
2. Maintain client confidentiality.
3. Take appropriate action to ensure the safety of clients and others.
4. Provide care for the client in a timely, compassionate, and professional manner.
5. Communicate client care in a truthful, timely and accurate manner.
6.Actively promote the highest level of moral and ethical principles and accept
responsibility for our actions.
7.Promote excellence in nursing by encouraging lifelong learning and
personal development.
8.Treat others with respect and promote an environment that respects
human rights, values and choice of cultural and spiritual beliefs.
9.Cooperate in every reasonable manner with the academic faculty and
clinical staff to ensure the highest quality of client care.
10. Use every opportunity to improve faculty and clinical staff understanding
of the learning needs of nursing students.
11. Encourage faculty, clinical staff, and peers to mentor nursing students.
12. Refrain from performing any technique or procedure for which the student
has not been adequately trained.
13. Refrain from any action of omission of care in the academic or clinical setting
that creates unnecessary risk of injury to the client, self, or others.
14. Assist the staff nurse or preceptor in ensuring that there is full disclosure
and that proper authorizations are obtained from clients regarding any form
of treatment or research.
15. Abstain from the use of alcoholic beverages or substances in the academic
and clinical setting that impair judgment.
16. Strive to achieve and maintain an optimal level of personal health.
17. Support access to treatment and rehabilitation for students who are experiencing
impairments related to substance abuse and mental or physical health issues.
I.A.4
18. Uphold school policies and regulations related to academic and clinical
performance, reserving the right to challenge and critique rules and
regulations as per school grievance policy.
Nursing process used in the CPNE
The nursing process provides the organizing framework for each Patient Care Situation
(PCS) in the CPNE. The nursing process consists of five distinct but interrelated steps
(assessment, analysis, planning, implementation, and evaluation) that should guide
you in the delivery of patient care. For the CPNE, these steps have been combined into
three phases for each PCS: Planning Phase, Implementation Phase, and Evaluation Phase.
The first three steps of the nursing process should guide your practice during the
Planning Phase of the PCS. Assessment, the first step of the nursing process, refers
to gathering and organizing data in relation to a patient’s health status. Initial
assessment data is obtained and organized from the patient’s record in the
Planning Phase.
The second step, Analysis, (nursing diagnosis) involves synthesizing the assessment
data to identify a patient’s actual or potential health problem(s). In the CPNE, you will
be required to select nursing diagnostic labels that describe your assigned patient’s
identified actual or potential health problems. You will be permitted to use CarpenitoMoyet’s Handbook of Nursing Diagnosis to guide you throughout the planning process
as you gather and interpret assessment data.
Planning, the third step in the nursing process, involves writing the plan of care for
your patient. During each PCS within the CPNE, you will be required to write a nursing
care plan that includes two diagnostic labels for the identified patient problems,
a measurable expected outcome (goal) for each diagnostic label, and two nursing
interventions designed to move the patient toward achieving the expected outcome.
The Implementation Phase of the exam encompasses the fourth step of the nursing
process, Implementation. During the CPNE, you will be required to initiate and
complete nursing actions/interventions designed to move your patients toward
expected outcomes.
Evaluation, the fifth and final step of the nursing process is conducted in the
Evaluation Phase of the CPNE. In this step, you will evaluate the plan of care you
have written by assessing the patient’s response to nursing care, documenting
any progress made toward meeting the expected outcome, and evaluating the
effectiveness of the nursing actions/interventions.
Overview
I.A.5
CPNE Objectives
The objectives evaluated during the CPNE must be achieved by all students to
complete the Excelsior College Associate Degree Nursing Program. The CPNE content,
described in depth in Unit IV, consists of the specific competencies that a beginning
Registered Nurse (RN) graduate must demonstrate by the end of a nursing education
program. These competencies are reflected in the following objectives.
• M
ake clinical decisions about patient problems in Patient Care Situations
(PCSs) using diagnostic reasoning, critical thinking, and standards of care.
• U
se interpersonal and communication skills to establish a caring relationship
with an adult or child patient in each PCS.
• F
ormulate nursing diagnoses consistent with your assessment data,
your patients’ responses to health problems, and the theoretical basis
for nursing care.
• W
rite nursing care plans that include measurable outcomes and interventions
related to your nursing diagnoses.
• Implement planned nursing interventions for adult and child patients in
your assigned PCSs.
• E
valuate the accuracy and the effectiveness of your nursing care plan for
each PCS based on clinical data, knowledge, theories, and standards of care.
Evaluation of Your Clinical Performance
Your performance will be evaluated by comparing your behaviors to pre-established
standards of behavior. The faculty have developed the guidelines for these behaviors
based on national standards of practice. These behaviors (also referred to as
Critical Elements) are clustered within Areas of Care reflective of the minimum
requirements for beginning RN practice. Critical elements are used as guidelines for
evaluating your performance. During the CPNE, you will be required to complete
all the Critical Elements for each of the assigned Areas of Care. For all components
of the examination, the PCSs and the Simulation Laboratories, you will be given
an assignment that will designate the Areas of Care to be performed. An Excelsior
College Clinical Examiner (CE) will evaluate your ability to perform the Critical
Elements. An Excelsior College Clinical Associate (CA) will oversee the administration
of the entire CPNE and ensure that the examination is conducted in a manner that is
consistent with the information published in the CPNE Study Guide. The roles of the
CA and CE are described in detail in Unit II.
I.A.6
I.B.1
UNIT I
Section B
Associate Degree Nursing Learning Resources
Features of the CPNE Study Guide
This study guide is not a text book, but it does include suggestions for learning
specific content. Consult references and text books to validate knowledge of
nursing content.
The CPNE Study Guide contains four units.
•U
nit I presents an overview of the examination and provides an introduction to this
study guide and to resources you can use while preparing to take the CPNE.
•U
nit II describes the structure and process of the CPNE. In addition to taking
you through the examination step by step, this unit presents the content
evaluated in the examination. Policies and procedures related to applying
for and taking the CPNE.
•U
nit III provides suggestions/strategies for studying, test taking, and stress
management techniques.
•U
nit IV presents a detailed description of the Critical Elements as well as
suggested learning activities to assist you in preparing for the CPNE. The unit
is designed to assist you in identifying the critical information to be learned
and in familiarizing yourself with the ways in which your knowledge will
be evaluated. Activities for critical thinking and application to practice, and
suggested learning resources are presented. You should spend the majority
of your preparation time studying the content presented in Unit IV.
Appendices are provided also to give you additional information and forms.
They include Definitions, Academic Policies, CPNE Student Orientation, Simulation
Laboratory Orientation, Simulation Laboratory Report Form, blank Student PCS
Response Form, Study Plan Analysis, PCS Scoring Tool, Reasonable Accommodation
Policy, and additional practice Care Plans.
I.B.2
CPNE Individual Advisement Calls
Nursing Faculty, who are part of the AD program at Excelsior College School of
Nursing are available by phone appointment to answer your questions about CPNE
content and process. While they cannot teach you the content they can answer
your questions, clarify your expectations, guide you to select learning resources and
discuss your study plan with you. Please be sure to read the Study Guide and consult
your textbooks prior to discussing your questions with faculty. If you are unfamiliar
with a nursing skill, please review it in your fundamentals or nursing skills textbook.
You may request a telephone appointment with a nursing faculty by calling the CPNE
Office. To schedule an appointment for a CPNE advisement call or to obtain additional
information, call 888-647-2388 (press 1-3-1-2 at the automated greeting) or email
[email protected]. Nursing Faculty will call you at your scheduled appointment
time. Please be aware that the CPNE preparation advisement call appointment times
are scheduled in Eastern Time. Organize your study materials and prepare your
questions prior to your appointment since CPNE preparation advisement calls are
scheduled for a maximum of 30 minutes each. Individual advisement calls are a
benefit of enrollment and are free of charge.
CPNE Information Mail Box
You can email questions about the CPNE content process to the CPNE faculty at
[email protected]. This mail box is checked daily.
Online CPNE Chat
Twice a month, the CPNE Nursing Faculty host an online chat on the EPN. This is an
informal time to discuss questions or concerns about the CPNE. It’s also a great time
to meet fellow students who are studying for the CPNE. You can check the current
schedule by going to www.excelsior.edu. Then, login to your “MyEC” page and view
the “EPN Chat Schedule.” Don’t worry if you miss the current chat, since all transcripts
of the chat are posted for 2 weeks on the EPN. To find out more about the EPN and
how to access it, visit the Excelsior College Web site at www.excelsior.edu, login and
click on the Electronic Peer Network link on your MyEC page.
Resources Available from the LEARN Team
For an additional fee learning opportunities other than previously listed are available
by calling the LEARN office at 888-647-2388 and at the greeting press 1-3-1-6. You
can also visit our Web site at www.excelsior.edu, login and click on the Nursing
Learning Resources link, where you can download information from our Web site.
I.B.3
Online Conferences
CPNE Online Conference—Beginning CPNE Preparation
This 14-day online conference is designed to provide the learner with one-onone interaction, to introduce the learner to the CPNE preparation. It will review
the structure and process of an actual CPNE weekend, the criterion by which the
learner will be evaluated, and how critical thinking and empowerment strategies are
used during the examination. In addition, the design, function and utilization of the
approved reference for Nursing Diagnosis will be reviewed.
CPNE Online Conference—Nursing Care Planning (NUR 3010)
This online conference is designed to be completed during a 14 day period.
The one-to-one guided learning interaction will enhance your skill in applying the
nursing process to solve patient problems. It is designed to provide you with the
skills necessary to maximize your nursing care plan preparation. The guided learning
interaction will enhance your understanding of the application of the nursing process
through self assessment and problem solving Patient Care Situations. The successful
completion of the CPNE requires you to develop and implement a nursing care plan
that is congruent with standards of nursing practice and medical regimens. This
online conference can be accessed at anytime during the fourteen-day session.
CPNE Online Conference—Documentation (500 Y)
This online conference is designed to be completed in seven days. The one-to-one
guided learning interaction will enhance the learner’s ability to accurately document
the required Critical Elements of the CPNE. In addition, the learner will self assess
the completed documentation to validate his/her understanding of the CPNE
requirements. This online conference can be accessed at any time during the
seven-day session.
CPNE Online Conference—Skills (500 S)
Providing direct and indirect care to the client in a number of clinical settings
requires that the registered professional nurse be competent in performing many
skills. This 4 week online conference provides learning modules to enhance
knowledge related to the clinical application for the following areas of care:
Asepsis, Vital Signs, Abdominal Assessment, Medication Administration, Neurological
Assessment, Peripheral Vascular Assessment, Respiratory Assessment/Management,
Wound/Skin Management and Musculoskeletal Management. Although this online
conference can be accessed at any time during the four-week session, there is a
time line for completing the module and answering the critical thinking discussion
questions.
I.B.4
Workshops:
CPNE Workshop
This three-day interactive workshop is designed to enable you to understand the
structure and process of the Clinical Performance in Nursing Examination (CPNE)
and validate your readiness to successfully complete the CPNE. Your ability to
perform the Areas of Care will be critiqued and feedback will be provided related
to a mock simulation lab and Patient Care Situation. Our team of Nursing Faculty
mentors provides these workshops in a variety of locations across the United States.
Workshops are open to those individuals who have completed the nursing theory
component requirements and 21 out of the 31 required general education credits.
(CPNE eligible)
Additional Resources:
CPNE Video (VHS or DVD) and interactive workbook
This 90-minute orientation video available in VHS and DVD format is designed as
a visual supplement to the Clinical Performance in Nursing Examination Study Guide.
The video presents selected aspects of orientation, laboratory simulations, and adult
and child care situations. The video is accompanied by an interactive workbook
which offers study strategies and suggestions on preparing for the CPNE. In addition,
it also provides written exercises using nursing diagnosis and critical thinking.
CPNE Skills Bag
The basic skill bag includes dressings, intravenous and medication supplies that
will allow students to simulate many aspects of patient care. The enhanced skill
bag includes a double teaching stethoscope and/or a wound like those used during
the CPNE. Either bag includes the guided learning booklet Nursing Clinical Skills: A
Thinking Approach. This has multiple learning strategies, two case studies and several
critical thinking exercises that will assist you in your preparation for the CPNE. Orders
can be made by mail or by fax directly through the vendor, Coursey Enterprises, using
the order form which is included with your CPNE Study Guide. If you do not have an
order form please contact the LEARN office at the number provided.
CPNE Flash Cards/CD
These 5×8 flash cards present each Area of Care with the required Critical Elements
in a compact, easy to read format. In addition, the flash cards contain helpful study
strategies and sample documentation related to that Area of Care. CPNE flash cards
are also available on audio CD.
I.C.1
I.C.1
UNIT I
Section C
Books, Journals, and Web sites
Throughout the CPNE Study Guide, the faculty has provided references to books,
journals, and Web sites to assist you in acquiring the knowledge needed for successful
completion of the CPNE. The references identified were selected to represent a variety
of print and non-print media sources. The presentation of a variety of references
is intended to provide you the opportunity to choose resources that best meet your
learning needs.
Use the textbooks you purchased to prepare for the theory examinations to review
theory and principles which support your performance of the Critical Elements.
Making sound clinical decisions and successfully applying the nursing process in
the CPNE will require that you practice from a current knowledge base. Textbooks
published more than five years ago may not contain the most current practice and
standards of care information. Although it is not necessary to purchase multiple
copies of textbooks covering the same content, you should arrange access to a wide
variety of recent and/or current resources as needed.
Organize your books and resources into a personal library. As you prepare for the
CPNE, the minimum recommended references in your personal library should include
content in the following areas:
• Fundamentals of nursing
• Medical-surgical nursing
• Nursing process and care planning
• Nutrition
• Patient teaching
• Pediatric nursing
• Pharmacology
Many students subscribe to nursing journals as another way to keep their knowledge
current. Students with limited recent acute care experience may find nursing journals
helpful for learning the required nursing content.
You may want to also consider subscribing to online journals for current information.
As you surf the web, add a site to your list of “favorites” or “bookmark” sites
where you have found helpful and reliable information. To determine if a site
contains reliable information, compare the content of the site to the content in your
recommended textbooks and the requirements of the CPNE. If there is a discrepancy
among the information sources, we recommend you do not use that site as a
reference.
I.C.2
References
This section provides the learner with references to both text books and journal articles.
Journal articles are available through the Excelsior College Virtual Library (ECVL) by visiting www.excelsior.edu/library and clicking on the Examination Resources link (login
is required). You may also find reference to CE (continuing education credit) articles.
The CE articles are provided for their content; there is no expectation that the learner
will actually take the CE exam, in fact in some instances the CE credits are no longer
available; however the content of the article is very relevant as a learning resource.
Note: Texts marked with an asterisk (*) are available through the Excelsior College
Bookstore (www.excelsior.edu/bookstore).
A. Nursing Theory and Clinical Decision Making
Select textbooks from this list to learn nursing theories and their application to
nursing process, nursing diagnosis, and development of a nursing care plan.
*Ladwig, G.B. & Ackley, B.J. (2006). Guide to nursing diagnosis. St. Louis: Mosby.
*Kozier, B., Erb, G., Berman, A., & Snyder, S. (2007). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice Hall.
Planning Phase
Carpenito-Moyet, L.J. (2003). Nursing care plans and documentation (4th ed.).
Philadelphia: Lippincott.
Doenges, M.E. Moorehouse. (2004). Nurses pocket guide, diagnoses, interventions and
rationales (9th ed.). Philadelphia: FA Davis.
*Hockenberry, M.J., Wilson, D., & Winkelson, M. (2005). Wong’s Essentials of pediatric
nursing (7th ed.). St. Louis: Mosby.
Monahan, F., Neighbors, M., Sands, J., & Marek, J. (2007). Phipps’ Medical-surgical
nursing (8th ed.). St. Louis: Mosby.
B. Clinical Practice Techniques and Procedures
The following references are specifically directed to nursing techniques and technical
procedures. Texts listed under each area of care also should be consulted for further
information. Journal articles are available through the ECVL by visiting www.excelsior.
edu/library and clicking on the Examination Resources link (login is required). Internet
addresses are provided as applicable for resources not available through ECVL.
*Hockenberry, M.J., Wilson, D., & Winkelson, M. (2005). Wong’s Clinical Nursing
Manual for Pediatric nursing (6th ed.). St. Louis: Mosby.
*Kozier, B., Erb, G., Berman, A., & Snyder, S. (2007). Fundamentals of nursing:
Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Prentice Hall.
I.C.3
*Smith S., Duell D., Martin B., & Martin C. (2004). Clinical nursing skills: Basic to
advanced (6th ed.). Upper Saddle River, NJ: Prentice Hall.
Asepsis
Guidelines for handwashing. (2002). Centers for Disease Control and Prevention
(CDC). Web site located at http://www.cdc.gov/mmwr/preview/mmwrhtml/
rr5116a1.htm
Hospital Nursing. (2001). Choosing and using gloves wisely. Nursing 2001, 31(6),
32–34.
Infection control nursing. Aseptic technique: Evidence-based approach for patient
safety. Preston, RM; British Journal of Nursing (BJN), 5/26/2005; 14(10): 544–6.
McConnell, EA. (1995, Oct. 25). Putting on sterile gloves. Nursing, 1995(10), 30.
Meshelany, CM. (May 1979). Post-op wound dressings: Your guide to impeccable
technique. RN, 42: 22-33.
Parini, S. & Myers, F. (2003). Keeping up with hand hygiene recommendations.
Nursing 2003, 33(2), 17.
Rothrock, J.C. (2006). What are the current guidelines about wearing artificial
nails and nail polish in the healthcare setting? Medscape Nurses, 8(2).
http://www.medscape.com/viewarticle/547793?src=mp
Sterile technique online programs: http://www.vlrc.fitne.net. (cost $25 to access
program).
Caring
Ekstrom, David N. (1999, June). Gender and perceived nurse caring in nurse-patient
dyads. Journal of Advanced Nursing (29) 6, 1393 –1401.
Leonard, B. (2001, May 31). Quality nursing care celebrates diversity. Online Journal
of Issues in Nursing (6) 2, Manuscript 3. http://www.nursingworld.org/ojin/
topic15/tpc15_3.htm
Lester, N. (1998). Cultural competence: A nursing dialogue. AJN, 98(8), 26–33.
Video: Concept Media (1990). Nurse Patient Interaction-three video series:
Therapeutic communication techniques, Blocks to therapeutic communication,
and Interactions for study. www.conceptmedia.com (series cost: $450).
Drainage and Specimen Collection
Caribbean Epidemiology Centre. (2006). Guidelines for the collection of clinical
specimens. http://carec.org/pdf/Guidelines-for-specimen-collection.pdf.
I.C.4
Lazzara, D. (2002). Eliminate the air of mystery from chest tubes. Nursing 2002,
32(6), 36-43.
New York City Department of Health. Specimen Guide. Nasopharyngeal specimen
collection for viral respiratory pathogens. www.nyc.gov/html/doh/downloads/pdf/
cd/asophar-specimen-guide.pdf
Skobe, C. The basics of specimen collection and handling of urine testing. BD
Newsletter Online. http://www.bd.com/vacutainer/labnotes/Volume14Number2/
Enteral Feeding
Arborgast, D. (2002). Enteral feedings with comfort and safety. Clinical Journal
of Oncology Nursing, 6(5), 275–280.
Bowers, S. (2000). All about tubes. Nursing 2000, 30(12), 41–49
Holman, C. (2006). Promoting adequate nutrition: using artificial feeding. Nursing
Older People, 17(10): 31–2.
Kohn-Keeth, C. (2000). How to keep feeding tubes flowing freely. Nursing 2000, 30(3),
58–59.
Metheny, N.A. & Titler, M.G. (2001). Assessing placement of feeding tubes. AJN,
101(5), 36–46.
Verification of feeding tube placement. (2005, May). AACN News, 22(5): 4.
Fluid Management
Astle, S.M. & Moriarty, M. (2005, May). Restoring electrolyte balance. RN, 68(5): 34–40
Heitz, U.E. & Horne, M. (2001). Pocket guide to fluid and electrolyte and acid-base
balance (4th ed.). St. Louis: Mosby
Holman, C. (2005, June). Promoting adequate hydration in older people. Nursing
Older People, 17(4):31-2.
Macklin, D. & Chernecky, C. (2004). Real world nursing survival guide: IV therapy.
St. Louis: Saunders
Rosenthal, K. (2006, July). I.V. rounds. Intravenous fluids: The whys and wherefores.
Nursing, 36(7): 26-7.
Routine postoperative management of the hospitalized: Management of
fluid imbalance, electrolyte abnormalities and acid-base disorders. From
ACS surgery: Principles & practice medscape. http://www.medscape.com/
viewarticle/512349_5
IV Therapy Course
I.C.5
Medications
Boyer, M.J. (2001). Math for nurses (5th ed.). Philadelphia: Lippincott, Williams
& Wilkins.
Capriotti, T. (2004, June). Basic concepts to prevent medication calculation errors.
Dermatology Nursing, 16(3): 245–248.
Cohen, M. (2001). Medication errors. Nursing 2001, 31(6), 18.
Curren A.M. & Munday L.D. (2000). Math for meds, dosages and solutions (8th ed.).
San Diego, CA: WI Publications, Inc.
Ignatavicius, D. (2000). Asking the right questions about medication safety.
Nursing 2000, 30(9), 51–54.
McConnell, E. (2001). Clinical Do’s & Don’ts. Nursing 2001, 31(6), 17.
Miller, D. & Miller, H. (2002). To crush or not to crush. Nursing 2002, 30(2), p. 50–52.
Togger, D.A., & Brenner, P.S., (2001). Metered Dose Inhalers. AJN, 101(10), p. 26 –32.
Trim J (2004, May 27). Clinical skills: A practical guide to working out drug
calculations. British Journal of Nursing, 13(10): 602– 6.
Musculoskeletal Management
Altizer, L. (2005 July/August). Hip fractures. Orthopaedic Nursing, 24(4), 283–294.
Hart, E.S., Albright, M.B., Rebello, G.N. & Grottkau, B.E.. (2006, July/August). Broken
bones: common pediatric fractures-part I. Orthopaedic Nursing, 25(4), 251–56.
Hart, E.S., Albright, M.B., Rebello, G.N. & Grottkau, B.E. (2006, September/October).
Broken bones: common pediatric fractures-part II. Orthopaedic Nursing, 25(5),
311–23.
Harvey. C.V. (2005 November/December). Spinal surgery patient care. Orthopaedic
Nursing, 24(6): 426–-42.
Kobziff, L. (2006 July/August). Traumatic pelvic fractures. Orthopaedic Nursing, 25(4),
235–241.
Morris L. (1988, February). Special care for skeletal traction. RN, 51(2): 24–9.
O’Hanlon-Nichols, T. (1998) Basic assessment series: A review of the musculoskeletal
system. AJN, 98(6) 48–52.
Oliver, S. & Hill, J. (2005, June). Arthritis in the older person: part 1. Nursing Older
People, 17(4), 25–29.
I.C.6
Oliver, S. & Hill, J. (2005, July). Arthritis in the older person: part 2. Nursing Older
People, 17. Issue 5, 23-5
Pullen, Jr., R.L. (2005, December). Tips for using dry heat therapy. Nursing, 35(12), 18.
Temple J. (2006 August 9 –15). Care of patients undergoing knee replacement surgery.
Nursing Standard, 20(48): 48–56, 58, 60.
Temple, J. (2004, September 29). Total hip replacement. Nursing Standard, 19(3), 44–51.
Pain Management
Ardery G., Herr, K., Titler, M., Sorofman, B., & Schmitt, M. (2003). Assessing and
managing acute pain in older adults: A research base to guide practice. Medsurg
Nursing, 12(1), 7–18.
D’Arcy, Y. (2005, March). Conquering pain: Have you tried these new techniques?
Nursing, 35(3): 36–42.
D’Arcy, Y. (2006, May). Controlling pain: Treating pain after a total joint replacement.
Nursing, 36(5): 26, 28.
D’Arcy, Y. (2006, July). Which analgesic is right for my patient? Nursing, 36(7): 50–6.
Hader, C.F., Guy, J. (2004, November). Your hand in pain management. Nursing
Management, 35(11), 21–27.
Joyner, N. (2006, March-May). Continuing education: a nursing approach to easing
pain. Connecticut Nursing News, 79(1): 11– 8.
Lafleur K.J. & Bauer, J.(2004, July). Taking the fifth [vital sign]. RN, 67(7): 30 –7.
Slaughter, A., Pasevo, C., & Manworren, R. (2002). Unacceptable pain levels. AJN,
102(5), 75 –77.
Peripheral Vascular Assessment
Ayello, E. (2000). On the lookout for peripheral vascular disease. Nursing 2000, 30(6),
64hh1– 64hh4.
Willis, K.C. (2001, February). Gaining perspective on peripheral vascular disease.
Nursing, 31(2): Hospital Nursing: 32hn1–4.
Lewis, A.M. (1999, December). Orthopedic and vascular emergencies! Nursing, 29(12),
54–56.
The Peripheral Arterial Disease (P.A.D.) Coalition Web site: www.padcoalition.org/
wp/membership/our-members/aanp/
I.C.7
Respiratory Assessment
Chest assessment by the letters (1983, January). Nursing, 13(1), 99.
Finesilver, C.A. (2001). Perfecting your skills: Respiratory assessment. RN, 64(4) 16–29.
Mehta, M. (2003). Assessing respiratory status. Nursing 2003, 33(2), 54–56.
Skin Assessment
Ayello, E.A. & Branden, B. (2001). Why is pressure ulcer risk so important? Nursing
2001, 31(11), 75 –79.
Ayello, E.A. & Branden, B. (2000). How and why to do pressure ulcer risk
assessment. Advances in Skin and Wound Care, 15(3), 125–132.
Baranoski, S. (2006, August). Pressure ulcers: A renewed awareness. Nursing, 36(8),
36 – 42.
Holloway, S. (2005, December 12). Skin care. The importance of skin care and
assessment. British Journal of Nursing (BJN), 14(22): 1172– 6.
Moore, Z. (2005, September). Pressure ulcer grading. Nursing Standard, 19(52): 56–64,
66, 68.
Vital Signs
Castledine G. (2006, March 9). Professional misconduct. The importance of
measuring and recording vital signs correctly. British Journal of Nursing (BJN),
15(5): 285.
Karch, A.M. & Karch, F.E. (2000). When a blood pressure isn’t routine. AJN, 100(3)23.
Wound Management
Feruson, M., Cook, A., Rimmasch, H., Bender, & S. Voss, A. (2000) Pressure ulcer
management: The importance of nutrition. Nursing 9(4), 163 –176.
Hess, C.T. (2001). Clinical guide wound care (4th ed.)., Philadelphia: Lippincott,
Wilkins & Williams.
Kozier, B., Erb, G., Berman A., & Snyder, S., (2004). Fundamentals of nursing:
Concepts, process and practice (7th ed.). Upper Saddle River, NJ: Prentice Hall.
Maklebust, J. & Sieggreen, M. (2000). Pressure ulcers: Guidelines for prevention and
nursing management (3rd ed.). Philadelphia: Lippincott, Wilkins & Williams.
Meshelany C.M. (1979, May). Post-op wound dressings: Your guide to impeccable
technique. RN, 42: 22–33.
I.C.8
Potter P.B., Erb, G., Berman A., & Snyder, S. (2004). Fundamentals of nursing
(6th ed.). Elsevier Mosby.
C. Communication and Culture
Review communication theory in your fundamentals textbook.
Campinha-Bacote, J. (2003, January 31). Many faces: Addressing diversity in health
care. Online Journal of Issues in Nursing, 8(1), Manuscript 2. http://nursingworld.
org/ojin/topic20/tpc20_2.htm
Dean, R.A. (2003). Native American humor: Implications for transcultural care.
Journal of Transcultural Nursing, 14(1), 62–66.
Deering, C.G. & Cody, D.J. (2002) Communicating with children and adolescents. AJN,
102(3), 34–41.
Finch, L. P. (2004, October). Understanding patients’ lived experiences: The
interrelationship of rhetoric and hermeneutics. Nursing Philosophy, 5(3), 251–257.
Lawrence, P. & Rozmus, C. (2001). Culturally sensitive care of the Muslim patient.
Journal of Transcultural Nursing, 12(3), 228–234.
McConnell, E.A. (1998, November). Using therapeutic communication. Nursing,
28(11), 74.
Overcoming barriers to effective communication. (1992, September). Nursing, 22(9),
32J–32L.
Trossman, S. (2002). How nurses, health care meet the challenge. American Nurse,
34(4), 1–5.
Women’s Health.gov
Explores various cultures and healthcare today
http://www.4women.gov/
Zoucha, R. (2002). The keys to culturally sensitive care. AJN, 100(2), 2466–2766.
HIPAA source
D. Ethics and Legal Aspects
Review content on ethical and legal aspects of nursing in your fundamental textbook.
Read about theses topics in nursing journals for the most current information. They
are usually presented as short special features listed as legal/ethical aspects, equipment, clinical news, etc.
I.C.9
Castledine G. (2006, March 9). Professional misconduct. The importance of
measuring and recording vital signs correctly. British Journal of Nursing (BJN),
15(5): 285.
Code of Ethics for Nurses with Interpretative Statements
http://nursingworld.org/ethics/code/protected_nwcoe303.htm
Dickerson, P.S. (2006, July-August). Clinical and organizational ethics: ethical
dilemmas: challenge and opportunity. Ohio Nurses Review, 81(4):15.
*Ellis, J.R. & Hartley, C.L. (2007). Nursing in today’s world (9th ed.). Philadelphia:
Lippincott, Williams & Wilkins.
Haddad, A. (2006, January). Ethics in action. An ethical argument for adequate pain
relief. RN, 69(1): 31–2.
HIPAA Advisory: Everything you want to know about the Healthcare Portability and
Accountability Act: regulations and more. http://www.hipaadvisory.com
E. Background Nursing Content
The references included in this section cover a broad range of clinical nursing areas.
Consult the table of contents and the index for specific areas of study.
Corbett, J.V. (2004). Laboratory tests and diagnostic procedures with nursing diagnoses
(6th ed.). Upper Saddle River, NJ: Prentice Hall.
*Curren & Munday. Math for meds: Dosages and solutions (9th ed.). Matthews Medical.
*Kee, J., et al. (2006). Pharmacology: A nursing process approach (5th ed.). St. Louis:
Sanders.
*Williams, S.R. & Schlenker, E. (2007). Essentials of nurtrion and diet therapy (9th ed.).
St. Louis: Mosby.
F. Test Taking and Stress Management
*Nugent, P. & Vitale, B. (2004). Test success: Test-taking techniques for beginning
nursing learners. Philadelphia: FA Davis.
*Audio CD: Just Relax (for stress reduction)
Internet Resources
Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/mmwr/
preview/mmwrhtml/rr5116a1.htm
I.C.10
HIPAA Advisory
Everything you want to know about the Healthcare Portability and Accountability Act:
regulations and more
http://www.hipaadvisory.com
Medscape
Latest medical news and information
www.medscape.com
Medscape Nursing
Latest nursing news and information
www.medscape.com/nurses
Medscape Nursing CE (continuing education)
Find free Nurses Continuing Education (CE) activities
www.medscape.com/nurses/ce
Minority Nurse
Many topics including cultural competencies
http://www.minoritynurse.com/
Nursing World
Official Web site of the American Nurse’s Association
http://nursingworld.org/index.htm
RN Journal
News and information for RNs, LPNs, LVNs, and Nursing Learners
http://www.rnjournal.com/journal.htm
The Peripheral Arterial Disease (P.A.D.) Coalition
www.padcoalition.org
Transcultural Nursing
Diversity in Health and Illness
http://www.culturediversity.org
I.D.1
UNIT I
Section D
Resources Available through Excelsior College
Available for Purchase through Excelsior College Bookstore
Excelsior College has partnered with MBS Direct to provide online bookstore services
to our students and examinees. Services include accurate online ordering, a wide
selection of new and used books—including over 7,000 titles in eBook format,
competitive pricing, a customer loyalty program, an online buyback program, and
a U.S.-based customer service available 7 days a week by phone and email
(Eastern time). In some cases current editions will be more recent than those listed in
this guide. Please see the most current list of CPNE® resources at our Web site.
• Phone: 800-325-3252
Fax: 800-325-4147
Monday –Thursday: 7:00 am to 9:00 pm
Friday: 7 am to 6 pm
Saturday: 8:00 am to 5:00 pm
Sunday: Noon to 4 pm
• Order online, anytime:
https://www.excelsior.edu/bookstore
• Write:
Excelsior College Bookstore
c/o MBS Direct
2711 W. Ash St.
Columbia, MO 65203
Be sure to allow sufficient time to obtain resources and to study
before taking the examination.
Mosby’s Guide to Nursing Diagnosis, Ladwig and Ackley
Pharmacology, A Nursing Process Approach by Kee, Hayes, and McCuistion
Clinical Nursing Skills: Basic to Advanced Skills by Smith & Duell
Dual Earpiece Teaching Stethoscope (skills bag)
Wong’s Essentials of Pediatric Nursing by Hockenberry.
Math for Meds: Dosages and Solutions by Curren & Munday
CPNE Videotape/DVD and Workbook by Excelsior College
Fundamentals of Nursing by Kozier
Phipps Medical-Surgical Nursing by Monahan, Neighbors, Sands, & Marek
I.D.2
Online Library Services
You have access to in-depth nursing resource information via the Excelsior College
Virtual Library (ECVL). To enter the ECVL go to www.excelsior.edu, log in, and
click on the ECVL link on your MyEC page. Take advantage of the many valuable
resources available to you through the ECVL. Toll free number: 877-247-3097;
email: [email protected].
Excelsior College Electronic Peer Network (EPN)
The EPN is a Web-based environment that enables enrolled Excelsior College
students (and alumni) to interact academically and socially. As a member of the EPN,
you will be able to identify students with common interests and contact them by
email. Through the EPN, you can form or join an online study group to collaborate
and exchange information with other students preparing for the CPNE. Participating
in study groups can be a great way to give and receive support as you work your way
through the study guide. You can also participate in live chats, exchange information,
share resources, and buy, sell, or trade used study materials. The Study Buddy Finder
is available through the EPN to help students find study partners. Membership in the
EPN is free of charge and available only to enrolled students. To access the EPN, log
in to www.excelsior.edu and click on the Electronic Peer Network link on your MyEC
page. For answers to questions about the EPN, email [email protected]. You can
announce your successful completion of Excelsior College exams or courses on our
Web site by sending an email to [email protected]. Your success will then
be posted in the Let’s Celebrate area of your MyEC page, which can be viewed by
other Excelsior College nursing students.
Excelsior College Graduate Resource Network (GRN)
The Graduate Resource Network (GRN) is a volunteer network of Excelsior College
graduates who recognize that you may want to talk with someone who has already
completed a degree program. GRN members are ready to share the ways in which
earning an Excelsior College degree has enriched their lives and improved their
careers. Members will correspond with you via email about the challenges you
may face when you return to school and about possible ways to manage work and
family obligations while you pursue your degree. They can share their experiences
concerning courses or examinations they have taken and may even be able to help
you locate learning resources in your area. For more information, contact the Office
of Alumni Affairs at [email protected]. Note: Be sure to call the CPNE Faculty when
you have questions about the content covered in the CPNE; GRN volunteers may
be quite removed from or unfamiliar with the content tested.
II
Unit II: Structure, Process, and Application Policies
Section A: CPNE Structure
Section B: CPNE Process
Section C: Application Policies and Procedures
II.A.1
UNIT II
Section A
CPNE Structure
CPNE Administration
The CPNE Administration is a comprehensive clinical performance examination
administered over 2-½ consecutive days at a hospital designated as an Excelsior
College test site. Clinical performance is evaluated during Patient Care Situations
(PCS) conducted on medical-surgical and pediatric units in a hospital setting and
during Simulation Laboratories conducted in a classroom setting using models and
mannequins. The CPNE consists of a minimum of 3 PCSs and a maximum of 5 PCSs
and a minimum of 1 Simulation Laboratory with a maximum of two Simulation
Laboratories. The CPNE is designed as one complete examination and must be taken
and passed in its entirety.
An Excelsior College Clinical Examiner (CE) will evaluate your performance of critical
thinking, diagnostic reasoning, and technical skills as well as your adherence to
standards of care and your knowledge from nursing and related disciplines. These
evaluations will be made by observing you as you perform the Critical Elements.
Critical Elements are single, discrete, observable behaviors that are used as guidelines
for evaluating your performance within the assigned Areas of Care. The faculty have
developed the Critical Elements, also referred to as standards of behavior required in
the examination, based on national standards of professional practice. The Critical
Elements evaluated reflect the minimum requirements for beginning RN practice.
Because the CPNE is a criterion-referenced performance examination, all Critical
Elements in all assigned Areas of Care must be performed as specified in this study
guide. These include Established Guidelines, which are the standards of nursing
practice that guide nursing actions. These standards are found in nursing textbooks
and references, accepted by the nursing community based on nursing and scientific
knowledge that lead to the best possible patient outcomes. An example of an
Established Guideline is palpating for brachial artery before taking a blood pressure.
Travel Information
Review the following travel information
•M
ake your hotel or motel reservation when you receive confirmation of your
CPNE appointment. A list of lodging recommendations will be included in your
confirmation packet. See unit II section E for information about scheduling and
confirming your CPNE examination appointment.
II.A.2
•D
etermine how you will get to the test site city. Search the Internet to see if the
test site hospital has a Web site. You will be able to get directions and find out
information about the hospital from the Web site. Plan to arrive the day before
your examination is scheduled to begin. Allow time for getting settled in and
for orienting yourself to the local area.
•S
chedule your departure for several hours after the examination is scheduled
to end to ensure that you have adequate time to reach the airport, train station,
or bus terminal. This should help you avoid feeling anxious and rushed as you
finish the examination.
•D
etermine how you will get from your place of lodging to the test site
hospital. Some lodging facilities offer shuttle transportation or have taxi
service available. Ask what options are available when you make your lodging
reservation.
• If you plan to drive yourself to the examination, obtain a road map and study
it before your trip. Determine the route you will take and mark it on the map.
Don’t forget to take the map with you and allow sufficient time for travel,
including unexpected traffic delays. Planning can help decrease the anxiety of
driving in an unfamiliar area.
• If you are planning to travel to the test site city with another student, agree in
advance to respect each other’s individual needs for space and time. Consider
that all students may not end the examination at the same time.
•C
onsider bringing a support person as a travel companion to help you feel
calm and relaxed before the examination. Your travel companion may drop you
off at the test site. Please note, however, that there may not be a designated
area at the test site for any companions to wait for you while you take the
examination.
•B
ring your CPNE appointment confirmation packet with you. This packet has
directions to the hospital test site and information about the time and place
where the CA will meet you.
•T
he CPNE is rarely cancelled due to inclement weather. Add additional travel
time to accommodate bad weather conditions, especially if you travel during
the winter months.
•E
xcelsior College reserves the right to modify structure and process of the
examination as required by circumstances at the test site. For example, in
addition to substituting an adult patient for the child PCS when no appropriate
pediatric patients are available, weather related issues may also be cause for
modification of the examination structure and process.
CPNE Structure
II.A.3
Standards of professional dress required for the CPNE
The faculty have established these standards of professional dress as one way to help
you maximize your success in the nurse-patient relationship. Because patients want
their safety ensured and have the right to refuse care they deem to be potentially
unsafe, you are required to adhere to these standards. During the CPNE, you will be a
representative of Excelsior College, the test site hospital, and the nursing profession
in the patient’s view. Patients naturally feel more confident when their caregivers
present themselves professionally.
You are required to dress for the CPNE according to the following standards.
•F
or Day 1 of the exam, wear clothes suitable for a professional work
environment. Day 1 attire is designated as “casual professional” because the
examination activities on that day will not involve any patient contact. For
Days 2 and 3, wear a white uniform. Any test site specific dress requirements
will be found in your confirmation materials.
•W
hite, one or two-piece uniforms, tailored pullover with a collar, button-down
shirts or scrub top, and pants that are clean, and pressed. White socks or
stockings should be worn. Colored or print undergarments must not be visible
through clothing.
•A
lab coat is permitted as long as it is free of any designations such as name,
title, or hospital insignia.
•S
hoes or sneakers are to be all white, rubber-soled, and clean; clogs are
not permitted.
• No visible body piercing is permitted except one pair of stud earrings.
• Jewelry should be limited to your watch and a wedding band if applicable.
• You will be asked to cover visible tattoos.
•H
air is to be well-groomed and, if shoulder length or longer, should be pulled
back. Hair should be a color that appears naturally in humans.
•N
ails are to be well-groomed. Acceptable nail polish colors include clear
or light-toned beige, coral, or pink. Nail detailing and accessories are not
permitted. Nails should be of a conservative length to prevent situations
that could jeopardize patient safety or impede patient care. Artificial nails
are not permitted.
• Avoid wearing perfumes or colognes.
• Gum chewing is not allowed during the PCSs.
II.A.4
If you arrive at the test site for Day 1 of the CPNE having chosen not to abide by
the standards of professional dress, the CA will ask you to modify your appearance
according to the criteria before returning to the examination on Day 2 for your first
PCS. Failure to abide by the standards of professional dress may result in termination
and failure of the examination.
Test Site
The CPNE is administered through four Regional Performance Assessment Centers
(RPACs) across the United States that were established to increase access to the
required Excelsior College performance examinations. The RPACs, listed from east
to west include:
NPAC
The Northern Performance Assessment Center located in Albany New York, with
testing in Albany, Schenectady, Utica, and Syracuse, New York.
SPAC
The Southern Performance Assessment Center located in Atlanta, Georgia, with
testing in Atlanta and Savannah, Georgia.
MPAC
The Midwestern Performance Assessment Center located in Madison, Wisconsin,
with testing in Madison and Racine, Wisconsin, Mansfield, Ohio as well as Plano
and Amarillo, Texas.
The examination is administered only in hospitals designated as test sites that have
contractual arrangements with the RPACs. Each center is responsible for scheduling
and administering the performance examinations in its region.
If you are employed at a hospital used as an Excelsior College test site, contact an
Excelsior College CPNE faculty member early in your preparation period to discuss
how your employment situation may affect your choice of RPAC. You may take the
CPNE at a test site hospital where you work if you have not worked on the units
used for the CPNE, including pediatrics, during the two-month period prior to taking
the examination. This rule is enforced to ensure that all students have an equal and
objective opportunity to demonstrate competence. It is also enforced to protect you
from other demands or intrusions during the examination period.
A map showing the Regional Performance Assessment Centers is located in
Appendix B.
CPNE Nursing Faculty Roles
The faculty associated with the CPNE include the CPNE Subcommittee, the AD
Nurse Faculty, Clinical Associates (CAs), and Clinical Examiners (CEs). The CPNE
Subcommittee consists of representative members from the Excelsior College Nursing
Faculty Committee, nurse administrators and staff development specialists from
the nursing community, a faculty member from Excelsior College and the School
of Nursing, and Deans from the Excelsior College School of Nursing, all of whom
are responsible for development of the CPNE content. See the list of subcommittee
members at the beginning of this study guide.
CPNE Structure
II.A.5
In addition to developing the CPNE, the associate degree nursing faculty provide
oversight for CPNE implementation and evaluation, and work with students with
special needs to arrange for accommodations in the administration of the CPNE. The
associate degree nursing faculty are also available for CPNE preparation advisement
by phone, email and the EPN. All student advisement is confidential and never shared
with the clinical faculty you will encounter at the examination.
The clinical faculty you will interact with during the CPNE include the CA and CE.
Typically, for each CPNE administration there is one Clinical Associate and two teams
of three Clinical Examiners. The number of CEs is equal to the number of students
testing during an examination. Please note that during training for a new Clinical
Examiner there is the possibility you may be observed by two Clinical Examiners.
You will be randomly assigned to a team of Clinical Examiners.
Clinical Associate
Your designated Clinical Associate (CA) will be present during the CPNE to make
sure you are tested objectively and that you have an opportunity to do your very best.
In addition to greeting you when you arrive at the test site hospital, your CA will:
• Coordinate and supervise the administration of the CPNE.
•E
nsure that the examination is conducted in a manner consistent with the
information published in this study guide.
• Orient you to the test site hospital and the Simulation Laboratory.
•B
e available to you throughout the examination to discuss concerns and
offer support.
•A
nswer your questions about the examination process at any time during
the examination.
•C
onsult with the CE as needed during the examination, ensuring that the
Critical Elements are interpreted according to standards of care.
• Review and verify any failure with the CE.
•R
eview and verify any failure with you to ensure that no extenuating
circumstances interfered with your ability to complete the Critical Element
in question.
•M
aintain the security and integrity of your examination materials throughout
the examination.
•C
omplete your Official Student Examination Record, which will summarize
the results of your testing in the Simulation Laboratories and Patient Care
Situations.
II.A.6
Clinical Examiner
The Clinical Examiner (CE) is an objective observer of your performance and a patient
advocate during the CPNE. Your CE will
•P
rovide an orientation to the patient care unit and any equipment necessary to
complete the PCS assignment
• Provide a written assignment at the beginning of each PCS
•O
btain permission from the patient or the patient’s family for a student nurse
to assist with that patient’s care
•V
erify the patient’s condition and assign Areas of Care based on the
patient’s needs
• Verify orders for medications to be administered during the PCS
• Notify hospital nursing staff about student nurse assignments
• Observe your performance at all times
•A
ct as a silent observer and not participate in any part of the patient care.
However, the CE may provide minimal physical assistance (e.g., moving
or positioning the patient) if you give the directions and if such assistance
does not interfere with the CE’s ability to observe your performance of the
Critical Elements.
•A
nswer questions not of a teaching nature that pertain to the patient
assignment or the patient care unit
•D
ocument your performance of the Critical Elements in all phases of the
examination
•E
nsure that your patients are protected at all times from Physical and
Emotional Jeopardy
• Interrupt the PCS if an extreme change in the patient’s condition or
environment occurs
• Consult with the CA as needed during the PCS
• Terminate the PCS if you omit or incorrectly perform a Critical Element
•D
ocument on the PCS Scoring Tool the Area of Care and Critical Element
failed as well as a description of the behavior that led to the failure
• Review the documentation of any failures with you
CPNE Structure
II.A.7
Clinical Associate and Clinical Examiner Qualifications
To be appointed as a Clinical Associate or Clinical Examiner, an individual must
• Possess a minimum of a master’s degree, with a major in nursing.
•H
ave taught the clinical content or supervised new graduates in the clinical
content included in the CPNE for at least three of the past five years.
•H
old a valid license to practice as a Registered Nurse in the state in which
the examination is to be administered.
• Hold proof of professional liability insurance.
•H
old a current certificate of completion of a course in cardiopulmonary
resuscitation from the American Heart Association or the American Red Cross.
•C
omplete the required Excelsior College School of Nursing training program
in objective performance assessment.
• Submit report of criminal background check.
Maintaining objectivity during CPNE Administration
•T
he CA keeps your examination records and will be the only person during the
CPNE who knows your background. If you discuss any questions or concerns
with the CA, the information will remain confidential and will not be shared
with the CE or hospital nursing staff. The CA will ensure that all aspects of the
examination are implemented as specified in this study guide or by the faculty
and dean of the School of Nursing.
•Y
ou will be assigned a different Clinical Examiner for each of the first three
PCSs except in unusual circumstances. For the first three PCSs, the CEs will not
know whether you have passed or failed previous Patient Care Situations.
•A
CE unable to render an objective assessment of a particular student will not
engage in evaluation of that student. During the Student Orientation you will
meet the CEs who will be evaluating your performance. If you have reason to
believe that a CE is unable to be objective, you may request another CE prior to
the beginning of the Simulation Laboratory. The CA will make changes in the
assignments as necessary.
•Y
ou are requested to withhold any personal information from the CEs. The CEs
will not ask questions pertaining to your background, residence, or current
employment.
II.A.8
•D
uring the PCSs, refer to yourself as “student” and your examiner as
“instructor” to lessen the focus on the testing nature of your interaction with
the patient. The patient will be told you are a second-year associate degree
RN student and that the CE will be evaluating your clinical skills within the
assigned Areas of Care.
Expected Student Behaviors
It is expected that during the CPNE you will
• Comply with standards of professional dress.
• Arrive at the test site at the specified time and location.
•P
erform in a manner that is consistent with expected standards for ethical and
professional practice.
•B
eepers, cell phones, PDAs, or programmable calculators are not allowed at
the test site hospital.
• Be in compliance with the Academic Honesty Policy (Appendix C).
•P
erform all aspects of nursing care for each PCS under the direct and
continuous observation of the CE.
•C
onsult with the assigned staff nurse during the PCS when clarification about
the patient’s condition or physical assistance with the patient is needed.
•C
onsult with the procedure manual or the nursing staff about specific
regulations, procedures, and equipment routinely used at the test site hospital.
•U
se resources available on the unit. Resources include policy and procedure
manuals, pharmacology texts, calculation charts, etc. You may use a calculator.
•U
se a teaching stethoscope that will be provided. It has two sets of earpieces to
facilitate simultaneous use by you and the CE.
•B
e responsible for the amount of time spent in each phase of the PCS. The CE
will not remind you of elapsed time.
•D
ocument all examination paperwork using “ECSN” after your name to
designate your nursing program.
• Maintain neutrality by not sharing personal information with the CE.
• Focus on your individual effort and performance.
CPNE Structure
II.A.9
We encourage you to ask questions of your CE and the staff nurse assigned to your
patient. Questions that are eliciting patient-specific or unit-specific information are
welcome. However, CE’s cannot answer questions of a teaching nature that pertain
to the implementation of patient care.
If your behavior is presumed to be unprofessional or disruptive at any time during
the examination, your Clinical Associate will have the authority to document such
behavior and verbally warn you that continuation of such behavior will result in
dismissal from the examination with the penalty of failure. Repeated episodes of
documented unprofessional behavior will result in termination and failure of the
examination and administrative review by Excelsior College with possible suspension
or dismissal from Excelsior College.
Student Orientation
Your designated Clinical Associate (CA) will greet you and the other examinees at the
location and time specified in your confirmation letter. Be prompt, as the examination
will begin at the specified time. Notify the RPAC administrative office if you encounter
a delay.
Please bring your photo identification, a watch with a second hand, a calculator, a
black ballpoint pen, and a pencil. Acceptable photo identification includes a driver’s
license, passport, or sheriff’s identification card. Before you begin the examination,
your photograph and signature will be compared to the photograph and signature
submitted with your application. Your CA will provide you with an identification badge
before you begin the exam.
Be aware that limited secure space will be available at the test site hospital.
We advise you to bring a minimum of personal belongings to the examination.
We do not recommend bringing a pocketbook or handbag. Books and study
materials brought to the test site hospital can be left in an unsecured conference
room designated for use during the examination. Taking study materials such
as this study guide or flash cards into the testing areas is a violation of the
College’s Academic Honesty Policy. Review the Academic Honesty Policy,
(Appendix C).
When all students have arrived at the test site, the CA will escort the group to a room
used for the CPNE Student Orientation and Simulation Laboratory Orientation which
will include:
•A
n overview of the schedule for the Simulation Laboratory and
Patient Care Situations
• An explanation of the roles of the student, CE, and CA
•A
n explanation of the policies and procedures that are specific to
the test site hospital
II.A.10
• A formal identification of all examinees by photo ID
• An orientation to the four stations of the Simulation Laboratory
We encourage you to ask the CA questions about specific Critical Elements or other
aspects of the examination during the general orientation session. This is the time to
ask last-minute questions about the examination process and setting. General content
questions should be answered before you arrive at the test site. There will be no
instruction related to nursing skills during orientation.
CPNE Schedule
Day 1
4
Sample Examination Schedule
4:15 pm−7:30 pm
Orientation to the CPNE and a hospital unit; Simulation Laboratory
7:30 am−2:00 pm
Day 2
4
Patient Care Situations 1 and 2
2:30 pm−3:30 pm
Simulation Laboratory 2 (if needed)
Day 3
4
7:30 am−5:00 pm
Patient Care Situations 3, 4 and 5 (4 and 5 as needed)
Break time is required during the CPNE. After you complete each PCS, your CA will
direct you to take a 20- to 30-minute break before beginning another component of
the examination. Use this time to rest and get something to eat and drink. Note: The
specific time you are to meet the CA will be indicated in your confirmation materials.
PCS Rotation
All examinees will draw cards at random to determine their rotation pattern. Your
rotation pattern will specify the rotation you will follow for adult and child PCSs.
Based on the card drawn by each student, the entire test group will be divided
into Teams I and II. Once the teams have been established, the CA will begin the
Simulation Laboratory Orientation.
To avoid creating unnecessary anxiety for yourself during the CPNE, we
recommend not discussing your experience with other students during breaks
or between test days.
II.B.1
UNIT II
Section B
CPNE Process
Simulation Laboratory
In the Simulation Laboratory portion of the examination, you will prepare and
administer Intravenous Medications through a primary/secondary setup and
Injectable Medications by intravenous push (IVP) and intramuscular (IM) or subcutaneous (subQ) injection. In addition, you will apply a wet to moist packing covered
by a sterile dressing to a Wound. A CE will directly observe and document your
performance of all relevant Critical Elements on a CPNE Simulation Laboratory
Report. Your performance of the Critical Elements will be timed at each of the
four required laboratory stations as follows:
Wound Protection:
15 minutes
Intravenous Medications:
20 minutes
Injectable Medications: IV Push
15 minutes
Injectable Medications: IM/subQ
15 minutes
You have up to two opportunities to pass the Simulation Laboratory component
of the CPNE with 100% accuracy. The required skills are performed on models
and mannequins in this setting. Because of the simulated nature of this component
of the examination, actual hand washing is not required as part of the Simulation
Laboratory.
Simulation Laboratory Orientation
On Friday evening the CA will read the orientation material (Appendix D) to the
student group, describing the supplies and equipment used and the process to be
followed for each laboratory station. Being familiar with the directions for completion
of the examination should help to increase your confidence level.
The CA will give you a CPNE Simulation Laboratory Report Form (Appendix G). You
will be asked to print your name on the form. You will carry this form with you to all
the required stations. A separate CPNE Simulation Laboratory Report Form will be
used for the repeat Simulation Laboratory.
II.B.2
You may ask the CA questions about the equipment and process of the examination
during the orientation. Because the Simulation Laboratory Orientation is part of the
examination, the CA and/or other students may not offer instructional assistance at
that time. Sharing instructional information with other students during the Simulation
Laboratory would violate the College’s Academic Honesty Policy.
Following the orientation, you will be allowed approximately 15 minutes to rotate
among the four stations and become familiar with the equipment and supplies. You
will be permitted to actually open and use equipment during the orientation period to
increase your confidence during the examination.
Once you have completed your hands-on familiarization with the equipment, the
Clinical Examiners (CEs) will be introduced for the first time. The Clinical Associate
will then pair students with CEs. Upon completion of the Simulation Laboratory
the CE will take the student to the patient care unit to receive a Patient Care Unit
Orientation and gather data for the first PCS assignment. At some test sites the group
will be separated into two sections—one section will complete the Patient Care Unit
Orientation prior to completing the Simulation Laboratory.
Completing the Simulation Laboratory
At each station you will be greeted by a CE who will read a statement that will direct
you to the assigned task and equipment. The CE will synchronize his or her watch
with the time on your watch. Then the CE will verbalize the starting time, writing that
time on the Simulation Laboratory Report. This will be done to make sure that both
you and the CE use the same time frame for completing the station. It is important
for you to keep in mind that the CE always adheres to the time frame. You will be
provided a Recording Form for calculations and recording dosages or flow rates prior
to medication administration.
If you incorrectly perform any of the Critical Elements the CE will consult with the
CA to discuss the circumstances which may affect a decision about whether that
Simulation Laboratory station is considered a failure.
Failure of the Simulation Laboratory will occur for any of the following reasons:
•Y
ou omit or incorrectly perform any Critical Element in the administration of
medication (intravenous by secondary method, IM or subQ, and IV push), or in
the changing of a sterile dressing.
• You violate Asepsis.
• You fail to complete each station within the allotted time.
•Y
ou exit the Simulation Laboratory component of the examination without
a valid reason before completion of the required stations.
CPNE Process
II.B.3
You have the opportunity to repeat any laboratory station failed during Laboratory 1
in Simulation Laboratory 2. A laboratory station may be repeated only once. If any
laboratory station is failed during Laboratory 2, the entire CPNE will be terminated
and failed at that time.
If you complete all the required Critical Elements before the allotted time has expired,
you may turn to the Clinical Examiner and say that you are finished. As a matter of
ensuring consistency, at each laboratory station the CE will read the ending question
“Have you completed all the Critical Elements for this station?” This will give you a
last chance to decide whether you have completed all the Critical Elements. Suppose
for a moment that you have completed all IV Push medication station Critical
Elements except recording the medications administered. The intention of reading the
ending question is to prompt you to double-check yourself and to give you a chance
to recognize and correct any omission in your performance of the Critical Elements.
Once you have completed all the laboratory stations, the CA will direct you to receive
your first PCS assignment and Patient Care Unit Orientation with your designated
clinical examiner.
PCS Framework
During PCSs, your ability to administer nursing care to adults and children with
common health problems will be evaluated. PCSs are organized around three
phases of the nursing process: planning, implementation, and evaluation. During
the Planning Phase you will have time to review the patient’s record in order to
collect and analyze assessment data prior to developing a plan of care. During the
Implementation Phase you will be providing nursing care to the patient according to
the Critical Elements in the assigned Areas of Care, which includes your nursing care
plan. The interventions you provide will be evaluated for effectiveness during the
Evaluation Phase of the PCS.
You will be allowed 2-½ hours to complete each entire PCS. Patients selected typically
require no more than 1-½ hours of nursing care during the Implementation Phase (the
time during which you will be caring for the patient). The other 60 minutes should be
divided between planning and evaluation. It is up to you to decide how you use the 2½ hour PCS time.
Your CE may grant an extension of time due to unexpected circumstances and/or
time delays during the PCS. For example, doctor visits are usually limited to 5-10
minutes. If a doctor spends 15-20 minutes with your assigned patient, the CE will add
the 15-20 minutes to your end time. The CE may allow up to an additional 30 minutes
(for a total time limit of 3 hours) for any delays in the PCS.
II.B.4
Orientation to the Patient Care Unit
On Friday evening, your CE for PCS 1 will orient you to the patient care unit and give
you your first patient assignment. You will have the opportunity to spend 30 minutes
becoming familiar with the unit and reading the chart of your assigned patient, but
will not converse with your assigned patient on Day 1. You may develop your Nursing
Care Plan (NCP) away from the hospital the evening prior to returning to the test
site for Day 2. This arrangement is intended to reduce the stress associated with the
first PCS. When you return to the test site hospital on Day 2 your CA will meet you
at a designated area and escort you to a room where you will be paired with the CE
for your first PCS. After a brief re-orientation to the patient care unit and unfamiliar
equipment the PCS 1 will be formally started.
You will receive a unit orientation with review of your PCS assignment kardex prior
to each subsequent Patient Care Situation. It is expected that your NCP for PCS 2 & 3
will be done within the 2-½ hour time frame allotted for the PCS.
Equipment Orientation
Orientation to equipment will be provided prior to each PCS. It is expected you will
have an understanding of the principles related to equipment use, however if you
have any questions you may consult the CE, the nursing staff, or access hospital
policy/procedure manuals. Orientation to the equipment will include a demonstration
of use and a chance for you to try the equipment. You will not be required to
troubleshoot when equipment alarms sound, however you will be responsible for
knowing whether the alarm indicates physical or emotional jeopardy for the patient
and then notify the clinical examiner or the assigned staff nurse. If equipment is only
available in the patient’s room, the CE may defer the orientation until you enter the
patient’s room. Common equipment includes but is not limited to:
• Digital, temporal, and tympanic thermometers
• Automated and manual blood pressure monitoring equipment
• Infusion control devices (ICD)
• Scales
• Respiratory hygiene equipment
• Pulse oximeters
• Continuous passive motion machines (CPM)
• Feeding pumps
You may be unfamiliar with specific models of equipment, but familiar with the
principles underlying their use. We therefore urge you to practice with different types
of equipment prior to scheduling the CPNE.
CPNE Process
II.B.5
The PCS Assignment
After the Patient Care Unit Orientation, your CE will review the PCS Assignment
Kardex with you. The PCS Assignment Kardex is a portion of the Student PCS
Response Form (Appendix H) on which the CE will write pertinent data about the
patient as well as the required and selected Areas of Care to be completed during
the PCS. Required Areas of Care will be designated with one asterisk (*) and Selected
Areas of Care with two (**).
At this time the CE will read aloud the information on the PCS Assignment Kardex.
You may ask the CE questions about the PCS assignment at any time during the PCS.
The assignment will include a total of five to six Areas of Care. The timing of the PCS
will begin after the CE reviews the PCS Assignment Kardex with you. The CE will state
the time the PCS is beginning and the expected end time.
Assigned Areas of Care
The Areas of Care you could be assigned are categorized as Overriding, Required,
and Selected. Each PCS assignment includes all overriding Areas of Care, the two
Required Areas of Care and three to four Selected Areas of Care.
The overriding Areas of Care encompass all nursing competencies and will be
evaluated in all aspects of nursing care throughout the entire PCS. They include
Asepsis, Caring, Emotional Jeopardy, Mobility, and Physical Jeopardy. A violation of
any overriding Area of Care will result in failure of that PCS.
Fluid Management and Vital Signs are Required Areas of Care that are assigned as
part of each PCS. This means you will be required to perform the Critical Elements
for these Areas of Care for each patient you are assigned. The CE will designate the
assignment for each of these Areas of Care on the PCS Assignment Kardex with one
red asterisk.
Selected Areas of Care are designated with two red asterisks on the line to the right
of the title of the Area of Care on the PCS Assignment Kardex. Selected Areas of Care
are chosen as part of the PCS assignment based on the clinical needs of the patient.
There are 16 selected Areas of Care. The Selected Area of Care Medications must be
successfully completed at least once during the CPNE.
Overriding Areas of Care
Required Areas of Care
Asepsis
Caring
Emotional Jeopardy
Mobility
Physical Jeopardy
Fluid Management
Vital Signs
II.B.6
Selected Areas of Care related to
Assessment
Management
Abdominal Assessment
Neurological Assessment
Skin Assessment
Comfort Management
Oxygen Management
Pain Management
Respiratory Management
Wound Management
Other Selected Areas of Care
Enteral Feeding
Irrigation
Medications
Patient Teaching
Criteria for Patient Selection
The CE will select a patient for the PCS who:
• Requires 5 to 6 Areas of Care
• Is expected to be in his or her room for the 2-½ hour PCS period
• Is in any state of consciousness as long as other criteria are met, and
• Is between the ages of 2 weeks and 17 years (for each child PCS) or 18 years
of age or older (for each adult PCS).
Patients will not be selected for the PCS if they:
• Are severely immunocompromised.
•R
equire highly specialized care or are in specialized care units such as ICU,
CCU, or maternity.
• Are receiving experimental drugs or are participants in a research program,
• Exhibit acutely disturbed behavior that interferes with the examination process.
•A
re deemed to be in imminent danger of death. (however, patients with
a written order “Do Not Resuscitate” or its equivalent may be selected for
the PCS.)
CPNE Process
II.B.7
Criteria for changing the patient assignment
You will be reassigned to another patient without penalty and given adequate time
to complete a new PCS if:
•A
change in your assigned patient’s condition interrupts the usual flow
of nursing care or interferes with the administration of the examination
as specified.
•A
change in the environmental conditions of the setting interrupts the usual
flow of nursing care or interferes with the administration of the examination.
The Planning Phase
The Planning Phase is the time during the PCS designated for analyzing the patient’s
assessment data and planning prior to initiating nursing care. You will have the
opportunity to review the patient’s record including flow sheets and medication
administration records. The CE will introduce you to the patient’s assigned staff
nurse when you are ready to receive a shift report about your patient.
For successful completion of the Planning Phase, write a Nursing Care Plan (NCP) that
is congruent with standards of nursing practice and the medical regimen as well as
calculate the flow rate for a gravity flow IV, if a gravity flow IV is assigned. Your NCP
will be evaluated using the guidelines specified in the Critical Elements. Your Clinical
Examiner will accept your Nursing Care Plan for the patient provided that:
•T
he two nursing diagnostic labels chosen are relevant to the assigned
Areas of Care.
• One of the two nursing diagnostic labels designates an actual patient problem.
• Expected outcomes are measurable and related to the diagnostic label.
• Interventions planned will move the patient toward the expected outcomes
and can be carried out during the PCS.
You may use black pen or pencil to write your Nursing Care Plan and document
on the Student PCS Response Form; however, use black pen to document on all
hospital forms.
The Implementation Phase
This is the period of time during the PCS when you will administer care to an
assigned patient. The care given will be evaluated according to the Critical Elements
of the assigned Areas of Care. Unless Clinical Decision Making (CDM) is invoked, all
of the Critical Elements in any given Area of Care are to be performed as specified in
this study guide.
II.B.8
The Implementation Phase will begin when the CE hands back your Nursing Care Plan
and reads you the statement “You have met the Critical Elements for planning and are
now ready to begin the Implementation Phase. All Critical Elements for Overriding,
Required, and Selected Areas of Care are now in effect.” The CE will write the
implementation start time on your PCS Response Form Kardex.
The CE will directly observe you during this entire period of time. The CE will be a
silent observer, checking off each Critical Element as you complete it. The CE will
simultaneously assess the patient, observing and documenting findings from which
your documentation will be evaluated. Remember that you are responsible for the
performance of all Critical Elements for an assigned Area of Care. If the test site
hospital policies or procedures vary from the behaviors identified as Critical Elements,
the CE will inform you of the hospital policy. Since this is a testing situation, you
will be accountable for completing the Critical Elements for the assigned Areas of
Care; the CE will be accountable for ensuring compliance with the test site hospital
policies or procedures. You may ask your CE questions about your PCS Assignment
at any time during the PCS, however, the CE cannot respond to questions that require
answers of a teaching nature.
During the PCS the CE may consult the CA to discuss:
•Q
uestions concerning your performance of the Critical Elements during the
PCS, whether an omission of a Critical Element, error in technique, or a
violation of an Overriding Area of Care has occurred.
•T
he situation when the patient’s condition and/or care requirements
change significantly.
•T
he situation when something in the environment prevents the completion
of an Area of Care.
The length of time it takes the CE and CA to confer will be added to your PCS
examination time.
Examples of statements a CE might use when stopping a PCS:
“We need to step out of the room now. Please bring your papers with you.”
“Lets check the time on your watch. It is now________; I need to clarify something
with the CA.”
Stopping the PCS means the CE has a question; it does not necessarily mean a failure
has occurred. The CE will offer you a comfortable place to wait and some water, if
available. Use this time to take a deep breath and try to relax. You may have to wait
since the CA may be involved with another student and CE. The CE and CA will return
after they have finished their discussion. At that time you will either be instructed to
continue or be told why the PCS was stopped. If you are not successful, you will not
be returned to the patient room.
When continuing with the PCS, the CE will say, “Please continue. The time on your
watch is now_________. We will be adding x minutes to your examination. Your end
CPNE Process
II.B.9
time now is_________. You may begin when you are ready. I want to remind you that
all Overriding, Required, and Selected Areas of Care are still in effect.”
The Evaluation Phase
This phase begins with data collection in planning and is ongoing throughout the PCS.
During evaluation your ability to document nursing care provided, report changes in
the patient’s clinical status, and evaluate a Nursing Care Plan will be assessed. Refer
to your NCP frequently throughout the Implementation Phase of the PCS to validate
your identified patient problem and determine the effectiveness of interventions and
patient progress toward meeting expected outcomes. After caring for the patient,
you are to objectively document assessments, data collected, nursing actions
implemented, and the observed patient response on the Student PCS Recording Form.
Finalize your NCP by selecting one priority nursing diagnosis form the diagnostic
labels identified in the Planning Phase and justify the reason you chose it as a priority.
To complete the nursing diagnosis, write a related factor for the selected patient
problem as well as signs and symptoms if it is an actual problem. If you select a risk
diagnostic label, complete the diagnostic statement by writing a related factor for the
selected problem. Your evaluation will be completed by writing a statement regarding
the effectiveness of the interventions and the patient’s progress toward achievement
of the outcome. During Implementation you may modify your plan of care to reflect
the patient’s condition. During the Evaluation Phase, evaluate your NCP to reflect your
patient’s actual condition. Modifications to the NCP should be consistent with:
• The patient’s clinical condition at the end of the PCS.
• Standards of practice, theory and the medical regimen.
• The Critical Elements of the Planning Phase
Before handing in your student PCS Response Form, review the list of Critical
Elements you created when organizing for the PCS. If you have forgotten to perform
any Critical Elements, you may go back to the patient to complete that Area of Care
except when there are timed or sequential Critical Elements that are to be completed
as designated. Once the time frame passes or the sequence of Critical Elements is
performed out of order, the PCS is stopped and failed at that time.
When you are confident you have performed and documented everything that is
required, hand in your Student PCS Response Form to the Clinical Examiner. The
CE will read the statement, “When you give your PCS Response Form to me, that
indicates you have completed all the Critical Elements for the entire PCS,” which
will signify the end of the PCS. Remember to take a deep breath, make a last check
that you have performed and documented every Critical Element required for your
assignment, and hand in your form confidently.
The CE will then review your Student PCS Response Form and score the Critical
Elements for the Evaluation Phase. After scoring the PCS, the CE will share the
results with you and escort you back to the conference room to share your results
with the CA.
II.B.10
Passing the CPNE
In order to pass the CPNE, you must successfully complete the four stations that make
up the Simulation Laboratory as well as two adult Patient Care Situations and one
child Patient Care Situation within the required time frames.
If you fail any portion of the examination, you will have the opportunity to repeat:
• Any failed station in the Simulation Laboratory during Simulation Laboratory 2
• One adult and one child PCS
If you pass all repeated laboratory stations as well as the repeat adult and/or child
PCS(s), you will pass the examination.
The CE for your last PCS will escort you back to the conference room where the CA
will give you a letter of congratulations that contains some tips to get you started
on your next milestone of passing the National Council Licensure Examination for
Registered Nurses (NCLEX-RN).
Failing the CPNE
If you leave the examination before completing all of the requirements, you will
automatically fail the examination and forfeit your examination fees.
If you are unsuccessful in any of the repeat PCSs or Simulation Laboratory stations,
the examination will be designated as failed at that time and you will be required to
repeat the examination in its entirety. For example, if two adult or two child PCSs are
failed in succession, the examination will be designated as failed and terminated at
that time.
You may repeat the CPNE a maximum of two times. If you wish to repeat the
examination and you did not accept an application packet at the test site, please
contact the CPNE Office at Excelsior College to request an application packet and then
submit it to the RPAC of your choice. No repeat appointment dates will be scheduled
by any RPAC until a new completed application is received.
Your completed application to retake the CPNE includes the following:
• A new completed CPNE Application Packet
• An updated Health Status Report
• Documentation of current CPR certification
• The appropriate examination fee
• A passport-type photograph
You can schedule a retake of the CPNE at the same or a different RPAC. Students
returning to retake the CPNE at the same RPAC may be examined by the same Clinical
Examiner(s). If you are repeating the CPNE and wish not to be assigned the same
CPNE Process
II.B.11
Clinical Examiner and/or Clinical Associate you were assigned during a previous
examination, please inform the Regional Performance Assessment Center (RPAC) staff
at the time you send in your application. We will make every effort to accommodate
your request. Failure of the CPNE at the third administration will lead to academic
dismissal from the School of Nursing. Students are eligible to again enroll five years
from the date of their withdrawal from the associate degree nursing program.
We welcome both positive and negative feedback about your examination experience.
If you have a grievance, please submit it in writing to the Dean of Nursing.
Appeal Process
If you fail the CPNE and wish to appeal the results the following should occur:
• Remain enrolled in your degree program during the appeal process.
•S
ubmit a typed and signed letter requesting an appeal within 30 days of failing
the CPNE to:
Dean, School of Nursing
Excelsior College
7 Columbia Circle
Albany, NY 12203-5159
If your letter is not signed, your appeal will be delayed until we receive a
signed copy of your letter.
•T
o expedite the appeal process your letter should include a clear and
concise explanation describing the scoring concern, or deviation from the
systematized conditions as stated in the study guide, that resulted in your
failure of the CPNE. Give the essential facts to enable the Examinations Appeal
Subcommittee to understand your grievance and point of view.
•T
he Dean, or designee, will forward your appeal to the Examinations Appeal
Subcommittee. All related records will be prepared in such a way as to protect
your anonymity.
•T
he subcommittee convenes monthly to review student appeals. The
subcommittee is composed of members of the Nursing Faculty Committee
and Excelsior College nursing faculty. All are voting members. The Dean (or
designee) is present as a non-voting member.
•T
he Examinations Appeal Subcommittee will review your appeal at the earliest
convenience of its members, but no more than 90 days after your request has
been received. You, the CPNE Clinical Examiner, and the Clinical Associate may
be consulted for clarification. After a thorough consideration of your appeal,
the decision of the Examination Appeals Subcommittee will be final. You
will receive a letter communicating the decision of the Examination Appeals
Subcommittee as soon as possible after the subcommittee meets.
II.B.12
• If you choose to appeal, you may not retake the examination before your
appeal has been reviewed. You will receive a letter acknowledging receipt of
your appeal and indicating the anticipated date your appeal will be reviewed.
After thoroughly reviewing an appeal, the Examinations Appeal Subcommittee is
empowered to render one of the following decisions:
“Uphold Failure”
This decision would be made if the subcommittee determined that
• standardized administration guidelines were followed
• standardized scoring guidelines were adhered to
• Clinical Examiner and Clinical Associate behaviors were correct
“Repeat Without Fee Without Penalty”
• principles of performance examination concepts were violated
OR
• t he Clinical Examiner or Clinical Associate interfered with your ability
to perform during the examination
OR
• t he CPNE Study Guide guidelines, and/or Critical Elements were unclear
or inconsistent with the situation
AND
• you did not successfully complete the requirements for passing the CPNE.
Although the fee for re-taking the CPNE is waived, the student is responsible for cost
of round trip travel to and accommodations at the test site. You have one year from
posted date of decision to repeat the CPNE without fee or penalty.
“Reverse to Pass”
• a scoring error was made
AND
• you successfully completed the requirements for passing the CPNE.
II.C.1
UNIT II
Section C
Application Policies
Eligibility
You are eligible to take the CPNE if
1. you are currently enrolled in the Excelsior College associate degree
in nursing program
AND
2. you have completed the required nursing theory examinations
AND
3. you have complete at least 21 of the 31 required general education credits
AND
4. if enrolled after 9/30/2007, you have completed the three Focused Clinical
Competency Assessment (FCCA) simulations.
Costs associated with taking the CPNE
The costs associated with taking the CPNE include an application fee, costs of study
materials and learning resources as well as travel, food and lodging when you take
the examination. Please note that fees are subject to change without notice. All
expenses associated with travel to the test site and meal/hotel accommodations are
additional costs not included in the CPNE fee.
Application Process
You will receive a Status Report from you academic advisor within 6 to 8 weeks of
completing your last CPNE eligibility requirement. If you think you are CPNE eligible
and have not received a Status Report confirming your CPNE eligibility, contact your
academic advisor to confirm your eligibility status.
To schedule an appointment to take the CPNE, electronically submit your application
5 to 8 months before you would like to take the examination. These time frames can
vary depending on application volume and desire for appointments at specific RPACs.
All examination appointments are assigned on a first come, first served basis.
II.C.2
To access the CPNE application and directions for submitting electronically, please
go to www.excelsior.edu/CPNEapplication.
A complete CPNE application includes:
•A signed “Documentation of Infection Control Practices Training” form.
(electronic signature available when applying online)
•A signed confidentiality statement. (electronic signature available
applying online)
• A completed application form.
• Completed payment preference form.
• Results of criminal background check.
•A current passport-size photograph of your head and shoulders. This
photograph will be compared with the photo identification you bring
to the examination. (may be uploaded for electronic submission)
•A Health Status Report completed and signed by your health care
provider.(may be uploaded for electronic submission)
•Evidence of current, through the last day of your CPNE, CPR certification
by an approved provider. (may be uploaded for electronic submission)
The first available appointment will be approximately 5 to 8 months after receipt of
all your required and complete application materials. You will be able to monitor
the status of your application by going to your MyEC page and clicking on CPNE
application status.
Health Status Report
A physical examination is required by a physician, physician’s assistant,
or a nurse practitioner within 12 months of exam date. See the Health
Status Report within the CPNE Application for requirements. The immunization requirements are based on the CDC “Healthcare Worker Vaccination
Recommendations” which can be referenced by going to www.immunize.org/
catg.d/p2017.pdf. Evidence of immunity is required for Measles/Mumps/Rubella
and Varicella.
Evidence of MMR immunity for those born prior to 1957 is demonstrated
by one of the following:
• Documentation of one dose of MMR vaccine
• Laboratory evidence of measles, mumps, rubella immunity (titre)
•Physician-diagnosed measles and mumps with laboratory evidence
of rubella immunity
Application Policies and Process
II.C.3
Evidence of MMR immunity for those born in and after 1957 is demonstrated
by one of the following:
• Documentation of two doses of MMR vaccine at least 28 days apart.
• Laboratory evidence of measles, mumps, rubella immunity (titre)
•Physician-diagnosed measles and mumps with laboratory evidence of rubella
immunity.
Evidence of Varicella immunity is demonstrated by one of the following:
• Documentation of two doses of Varicella vaccine at least 28 days apart
• Laboratory evidence of varicella immunity (titre)
• Physician-diagnosed varicella or herpes zoster.
It is not necessary to send copies of laboratory results with the health status report;
healthcare professional documentation of immunity is all that is required.
Confirming CPNE Date
The CPNE is typically administered on every weekend with the exception of national
holidays by individual appointment; however, some test centers schedule midweek
examinations annually. The first available examination date at the test site facilities will be approximately 6 −8 months from the date your completed application
packet has been processed. Please check EPN—Clinical Performance in Nursing
Examination Discussion Board for current RPAC scheduling information. You may
monitor the status of your application by going to your MyEC page and clicking on
CPNE application status.
After your complete application has been processed, confirmation materials designating an assigned examination appointment date and test site will be sent to you.
To confirm your assigned examination appointment date, you are to (1) sign the
boxed area on the confirmation form designating your acceptance or decline of
the examination appointment and (2) return that form to the RPAC within 14 days.
If you do not return the confirmation form within 14 days, you will be charged an
administrative fee. If you are unable to attend the CPNE on the assigned examination
appointment date, you may decline that first examination appointment without being
charged an administrative fee as long as your decline is received in writing at the
RPAC administrative office within 14 days.
II.C.4
Cancelling/Postponing Examination Date
If you find it absolutely necessary to cancel your confirmed examination appointment,
you should immediately notify in writing the administrative office of the RPAC where
your examination is scheduled. You will incur an administrative fee if you choose to
cancel or postpone a confirmed examination appointment. Therefore you should only
confirm the assigned examination appointment date when you are prepared to take
the examination and when you are sure you will be able to keep this examination
appointment.
Changing my CPNE Date
If you decide that you need to reschedule your CPNE for a later date you will
be charged a cancellation fee. The fee for canceling and rescheduling the CPNE
is as follows:
30 calendar days or more prior to scheduled CPNE
4
$100.00
21−29 calendar days prior to scheduled CPNE
4
$525.00
4
$785.00
4
Forfeiture of CPNE fee
You will be permitted to cancel/postpone up to three (3) examination appointments
using the same CPNE Application. After you have canceled/postponed your
third examination appointment, you will be required to submit an updated CPNE
Application and all necessary documents. Remember that you may access the CPNE
application and instructions for electronic submission by going to www.excelsior.
edu/CPNEapplication.
Transfer Policy
A $100.00 administrative fee is charged when a student transfers a performance
examination appointment from one Regional Performance Assessment Center (RPAC)
to another. This $100.00 fee will be deducted from the amount originally submitted by
the RPAC that is transferring your application.
Additional Study Guide Policy
The first copy of a nursing performance examination study guide is sent to the
student when eligibility requirements are met. There is a $35 fee charged for
second or duplicate copies of the CPNE Study Guide.
Application Policies and Process
II.C.5
Emergencies
The Excelsior College policy regarding illness or changes in health status is consistent
with your responsibility as a health care provider to not knowingly expose yourself,
your patients, hospital staff and visitors, or members of the examination team to the
risk of illness.
• If your health status changes from the time you submit your Health Status
Report with your CPNE application, you will need to present specific
documentation that updates your Health Status Report and verifies medical
clearance prior to your arrival at the test site hospital.
• If you become ill on the way to your examination appointment but choose
to participate in the examination anyway, you will need to obtain medical
clearance to participate in the CPNE. Your Clinical Associate can arrange for
a health evaluation at the test site hospital’s emergency department when
you arrive. Any fees for related medical and hospital services will be your
responsibility.
• If at any time during the examination you become ill or exhibit behavior
determined unusual or unexplainable, your Clinical Associate will have the
authority to stop the examination and seek a medical evaluation for you.
If you do not receive medical clearance to re-enter the clinical facility, the
examination will be terminated and the examination fee forfeited.
• If during the evening of the examination (day 1 or 2) you become ill, notify your
Clinical Associate. Your Clinical Associate has the authority to require you to
seek a medical evaluation and be cleared to re-enter the clinical facility. If you
are voluntarily terminating your examination due to illness, please notify your
Clinical Associate as soon as you have made the decision not to continue.
• If you become ill with a communicable disease within 10 days of being at the
hospital for your examination appointment, notify Excelsior College of your
illness in case any follow-up is required. If you have questions regarding the
contagious nature of your illness, please call the CPNE faculty.
Accommodation for Disabilities
(including latex allergies and hearing deficits)
Excelsior College makes every effort to accommodate examinees with physical,
psychological, or learning disabilities insofar as possible, given the content and
requirements of the CPNE. If you have a condition that may interfere with your ability
to perform the Areas of Care as described in this study guide, it is important that you
review Policy # 121303: Reasonable Accommodation for Students with Disabilities
(Appendix M).
II.C.6
This examination is held at locations that are accessible to individuals with
disabilities. If auxiliary aids or services are needed, please follow the directions below
to request an accommodation. Please plan ahead and request the accommodation as
soon as possible or 45 days prior to your scheduled testing date.
To request accommodations for the examination:
1. Request a “Disability Services Student Information Packet” by calling toll free
888-647-2388, at the automated greeting press 1-1-8631. Students may also
access this information by going to www.excelsior.edu/disability_services
to view and download directions and forms.
2. Complete and submit the “Disability Registration and Request for
Accommodation Form” found in the packet. Please send the completed form to
the Disability Services Coordinator, Excelsior College, 7 Columbia Circle, Albany,
NY 12203-5159.
And
3. Use the “Release of Information Form” from the packet to request documentation
of your disability from a specialist as outlined below. While it is preferable that
your documentation be submitted to the College with your Request Form, the
specialist may mail it directly to the Disability Services Coordinator. Please note
that because of federal privacy regulations we are unable to accept any
documentation via fax.
• If you have a physical and/or psychological disability: Submit a letter of
validation from a physician who specializes in the area of your physical and/or
psychological disability. The physician’s letter should be on official letterhead
and describe the nature of your disability, the limitations it imposes on your
performance, and any accommodation(s) required. The letter also describes
your ability to care for patients in an acute care setting.
• If you have a learning disability: Submit either a diagnostic report
prepared by a certified professional from the counseling office of another
college or a letter from a physician or clinical psychologist who specializes
in learning disabilities. The letter from the certified professional, physician,
or clinical psychologist is to be on official letterhead and describe the nature
of your disability, the method of diagnosis, the data collected to verify your
condition, and any accommodation(s) required. The letter should describe
your ability to care for clients in an acute care setting.
Application Packet
II.C.7
CertifiedBackground.com
CertifiedBackground.com is a background check service that allows students to purchase their own background check. The results of a background check are posted to
the CertifiedBackground.com web site in a secure, tamper-proof environment, where
the student, as well as organizations can view the background check.
To order your background check from CertifiedBackground.com, please follow the
instructions below:
1)
Go to www.CertifiedBackground.com and click on “students”
2)
In the Package Code box, enter the appropriate code (SEE BELOW)
3)
Select a method of payment
4)
Follow the onscreen instructions to complete your order
Once your order is submitted, you will receive a password via email to view the
results of you background check. The results will be available in approximately
48 –72 hours. Print the results of you background check and submit electronically
with your CPNE application.
Code Information
If you are applying to NPAC or MPAC for your CPNE please enter the Package Code:
XC39. The cost for the basic background check will be $12.00.
If you are applying to SPAC the required background check for one of the test sites
in Georgia is requiring a more in depth background check, consequently the cost is
$42.00. If you have worked two or three different jobs within the past 7 years there
will be an additional fee of $7.00 for each employment verification beyond one, not
to exceed three. Additional fees may apply for companies that outsource verifications.
Please use the following Package Codes when applying to SPAC for your CPNE:
Enter XC39-1 if you have had one job within the previous 7 years
Enter XC39-2 if you have had two jobs within the previous 7 years
Enter XC39-3 if you have had three jobs within the previous 7 years
II.C.8
III
Unit III: Preparing for the CPNE
Section A:
Learning Readiness
Section B:
Learning Strategies
Section C:
Managing Stress
III.A.1
UNIT III
Section A
Learning Readiness
Preparation
Prepare for the CPNE by first determining your readiness for learning then developing
a long-term study plan. Successful preparation for the CPNE will depend on
several factors including your motivation, time management, creation of a learning
environment, personal life demands, and health care experience.
Careful preparation is essential for ensuring success on the CPNE. Since the CPNE is
a performance examination, you should anticipate using strategies that are different
from those you would use to prepare for a theory examination. Merely reading the
study guide or the information in the suggested references will not prepare you to
perform the required nursing behaviors. To adequately prepare for the examination
you should practice performing the Critical Elements with a qualified professional
observing your performance while comparing it to the Critical Elements.
You may have acquired some of the knowledge and skills evaluated in this
examination in your previous educational or work experience. If so, your examination
preparation time should be spent integrating that knowledge and skill with the
knowledge and skills required in the examination and practicing the required nursing
actions. You may need to modify knowledge and skills to reflect RN practice. Learning
new information may require letting go of old ways of knowing and doing in order
to perform at a higher level. Your amount of preparation should reflect the complexity
of the skills evaluated in an end-of-nursing-program summative performance
examination.
From 2003 through year to date 2005, analysis of success rates for students taking
the CPNE indicate 63% of the first-time examinees passed, 63% of the second-time
examinees passed, and 57% of the third-time examinees passed.
“After preparing for approximately six months to take the CPNE, I was
unsuccessful in my first attempt. I thought I was so well prepared and had
the years of experience to guide me along. I know now that my nerves got the
best of me and caused me to make two mistakes in areas that I know very
well. After that failure, I turned to the Internet and found the Electronic Peer
Network. At first I would browse and see what others had to say. Then one day
I got an email from someone who also did not pass on her first try. She was
so encouraging and had lots of advice to offer. I participated in the educator
facilitated chat held the month prior to retaking the CPNE, where all I could
do was focus on how to get past the stress level I was feeling. Although I still
needed a lot of work I finished the one hour chat feeling somewhat better. With
lots of hard work and perseverance, I was successful in my second attempt
[only four months later]…Preparing was certainly helpful to me.”
Kathie LaChance, Rhode Island
III.A.2
While it is assumed that you have already developed basic time management skills
which include balancing personal and professional life demands, the following
suggestions are offered.
•B
uild your support system by sharing your potential plans with people
you can count on to support you in pursuing your goals.
• Set a deadline date for each step of your study plan.
•Determine the best times to study, taking into account your personal
and employment demands.
•Choose times when you are most alert and uninterrupted for learning
new information. During those hours when you tend to be less alert,
review previously learned material.
•Coincide your practice sessions with times when a qualified person
will be available to evaluate your performance in accordance with
the Critical Elements presented in this study guide.
Your learning environment encompasses more than the actual physical space within
which you will study or practice your skills for the CPNE. It also includes adequate
resources to facilitate success. In addition to recommended study materials and
equipment, people to support and validate your learning are important resources
needed for successful CPNE preparation. What do you need to do to create an
environment that will support your learning?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
The following are suggested ways to enhance your learning:
• Use the recommended materials from the Excelsior College Bookstore.
•Create a study space where all needed resources are readily available.
Set up space in which to simulate and practice clinical skills in your home.
•Investigate options for practice experiences in your place of employment
or in your community. A staff development educator or faculty member
of a local college of nursing may be willing to observe your performance
of the Critical Elements.
• Investigate learning resources available through Excelsior College.
•Visit your local public nursing, medical, and/or online library. In addition to
offering access to resources such as books and computers, libraries provide
quiet study environments.
Learning Readiness
III.A.3
•Consider playing background music while you study to decrease environmental
distractions and help you concentrate.
•Establish control over potential distractions such as paying bills, cleaning your
house, or preparing snacks that may prevent you from beginning to study at
your scheduled time or interrupt your concentration.
Use the following chart to identify readiness to begin CPNE preparation.
Factors affecting my readiness to begin CPNE preparation
Factor
Yes
No
I am motivated to begin CPNE preparation.
I have identified ways to deal with obstacles that could arise during
CPNE preparation.
I am confident in my ability to obtain study resources and arrange learning
experiences to facilitate my learning.
I have others in my life who are willing to support and encourage me when
I am preparing for the CPNE.
I can manage my time well.
I have access to qualified practitioners to help me evaluate my performance
according to the Critical Elements.
I have the required learning resources readily available.
I can communicate my learning needs concisely and clearly.
I have access to the equipment I will need when I practice my nursing skills.
I am able to adjust my personal and professional life demands to
accommodate the addition of study and practice time.
I have carefully reviewed each area of the study guide and I understand the
requirements of the examination.
I am ready to begin my preparation for the CPNE.
III.A.4
“Planning your time wisely is no trick or art…you just do it. You make up
your mind that you have a task to perform and this task has a completion
date. You set your date and then plan your time around it. Look at the whole
picture and then narrow it down form the general to the specific. Accomplish
one thing at a time. To do so much in a little time may be defeating your
purpose. Concentrate on one thing at a time and then move on to the next,
and the next, etc. Before long your single tasks have now grown to a
completion of many tasks.”
Deitra Wade, Tennessee
III.B.1
UNIT III
Section B
Learning Strategies
The following suggested learning strategies can be customized to meet your needs.
When choosing learning strategies, remember that you are working to master a
complex set of skills. Choose strategies that will help you integrate critical thinking
and diagnostic reasoning in your care of hospitalized patients.
Know the Study Guide
The CPNE Study Guide describes the content you will need to know and demonstrate
throughout the examination. Be sure you have the most current edition of the study
guide before you begin your study. Contact Excelsior College to verify that your
edition of the study guide is current.
Practice, Practice, and Practice
One of the most helpful ways to prepare for the CPNE is to practice in your clinical
work setting or a simulated setting. Seek out Registered Nurses to assist you as
you practice. Professional nurses and other practitioners in your work setting may
be willing to answer questions and demonstrate techniques to help you learn.
Be sure you and your mentor have the CPNE Study Guide available for reference,
since the study guide explains the scope of the skills and techniques you must be
able to demonstrate in the CPNE.
Scope of Practice
Students enrolled in campus-based programs engage in clinical learning activities
under an exempt clause in the Nurse Practice Act in their resident states. This clause
enables them to perform patient care as RN students under direct clinical supervision
without state licensure. Students enrolled in an Excelsior College nursing program
are not eligible under this clause because they are not enrolled in an instructional
program and are not provided on-site direct clinical supervision except at the time of
the CPNE. While preparing for the CPNE and working directly with patients, you may
perform only those activities normally permitted within your scope of practice in your
employment setting.
III.B.2
Evaluate your current knowledge
Complete the self evaluation tool (Appendix J) and rate yourself on your competence
and confidence for each Critical Element for that Area of Care. In areas where you
rate yourself as having little or no competence and confidence, seek additional
learning opportunities to practice those skills. While you may feel quite confident with
regard to some Areas of Care and Critical Elements, you should still review those
Critical Elements and incorporate practice of those Areas of Care in you study plan.
You should devote additional study and practice time to the Critical Elements within
the Areas of Care you feel less confident about.
Study each Area of Care in depth
Select an Area of Care and review the suggested learning resources regarding that
area. Review nursing techniques and procedures required within the Areas of Care
as explained in textbooks and other references. Reflect on the underlying principles.
Consider nursing diagnoses that relate to each Area of Care. Think about the
adaptations that you may need to make because of a patient’s age or condition. For
example, what is the usual pulse range for an infant versus and elderly adult? Does
blood pressure cuff size have an effect on the measurement obtained? If you have
a question about a particular Area of Care, check your references for an answer
or contact a CPNE Nurse Faculty member for assistance. During the CPNE, your
understanding of the nursing theory supporting the clinical skills will be assessed
based on observance of how you perform the Critical Elements within the established
guidelines for practice. Watch someone in your practice environment, such as
shadowing an RN, or view the Excelsior College CPNE videotape. Evaluate
the performance you are observing according to the Critical Elements.
Study the references
The CPNE evaluates the application of the nursing knowledge you have acquired
throughout the nursing program. Use references from all your theory examinations
to aid your study process including textbooks focusing on fundamentals of nursing,
medical-surgical, clinical skills, physical assessment, and pediatric nursing. Check
with your local library or schools of nursing in your area for the availability of
journals, computer-assisted instruction, videocassettes, and audiocassettes. We have
suggested online resources that we know to be available at the time of printing of
this study guide. New online resources are available daily. If using online resources,
remember to evaluate the credibility of each source of information. The following
Web site is a good place to begin to critically analyze the material you find on the
Web: http//www.library.jhu.edu/elp/useit/evaluate/index.html. Do not use a site
if its resources contradict the recommended textbooks or the CPNE Study Guide. In
addition, review content related to anatomy and physiology, microbiology, lifespan
Learning Strategies
III.B.3
developmental psychology, and other related sciences as needed. Integrate nursing
knowledge learned from textbooks and other study materials into your current
practice.
Integrate your study into your clinical practice
Concentrate on one or two areas for a specified period of time. Review this
information before you begin performing each Area of Care for a patient. Evaluate
your performance against the Critical Elements. How did the behaviors you
demonstrated in your performance compare with the behaviors defined as Critical
Elements? What can you do to become more competent or feel more confident in
your performance? In addition, practice documenting all assessment findings and
pertinent information required by the Critical Elements on sample copies of the
Student PCS Response Form (Appendix H). Compare your documentation to the
Critical Elements. Determine if you included all information necessary for successful
completion of the Recording Critical Elements. If you are unable to practice in your
work setting, ask staff development personnel in your institution to set up simulations
for the Areas of Care you need assistance with.
“Since I was unable to practice regulating IV fluids in my work environment,
I set up an IV at home. I watered my plants by delivering the water via a
gravity flow IV.”
An anonymous student
Develop Nursing Care Plans (NCP)
Practice writing nursing care plans using the sample form in Appendix H. The patients
you regularly care for at work are great cases for you to use when developing care
plans. As you go about your daily clinical work, think about and record the types
of information you would need to collect in order to complete a care plan and then
collect relevant data. During your study time, use this data to formulate your nursing
care plan. If you aren’t working directly with patients, practice using case studies
you may find in references you are using to study. Evaluate your care plans and,
if possible, ask a RN to validate them using the Critical Elements for Planning and
Evaluation Phases and give you feedback. Excelsior College faculty are available by
email or phone appointment to answer your care plan questions. If you think you
need additional support attend an Excelsior College CPNE Workshop, participate in
a NCP Teleconference, or Online Conference for assistance. If you work in a clinical
setting that uses a care map/critical pathway documentation system, practice
restating the identified problems as nursing diagnoses.
III.B.4
Create a mock situation
Think of a patient who might require a particular kind of care. For example, a patient
has a history of Chronic Pulmonary Obstructive Disease (COPD) and is admitted with
pneumonia. A possible Area of Care to assign would be Respiratory Management.
What are the Critical Elements within Respiratory Management you would be
required to perform? Prepare a mock Patient Care Situation (PCS) Assignment Kardex
using a copy of the blank forms located in Appendix H. Include the Areas of Care
that would be included in your assignment. Role-play the situation in a clinical or
simulated setting. How would you organize your care? What skills do you need to
have to perform these Areas of Care? Visualize the patient, the patient room, and
the equipment you will use. Perform the Critical Elements as though this were the
examination. Document all information specified in the Critical Elements in the
appropriate sections of the Student PCS Response Form.
Don’t try to do everything at once
Focus on all required Critical Elements for one Area of Care before moving to another.
Once you have mastered all the required Critical Elements for each individual area
of care, role-play the PCSs, acting out the required Critical Elements for multiple
Areas of Care.
Picture yourself as successful
Develop a mental picture of yourself as a competent and confident practitioner.
Picture yourself performing competently during the CPNE. Visualize calmness,
organization, and professionalism as you plan, implement, and evaluate your
nursing care during each PCS.
III.C.1
UNIT III
Section C
Managing Stress
Don’t underestimate the effects stress can have on your preparation for and
completion of the CPNE. Successful or not, one of the most common comments we
hear from students once they complete this exam is, “I never knew I would feel so
stressed out.”
Several different factors may contribute to this feeling. They can range from not
knowing what to expect in the exam to being totally unfamiliar with the city or
hospital test site. Although you may not be able to control whether or not you
experience stress, you can learn to control your response to it.
Everyone experiences a certain amount of stress, some more often or more intensely
than others. While limited amounts of stress may help motivate you to take some kind
of action, too much stress can compromise even your most basic skills performance.
If stress were measured on a scale from one to five, where one is relaxation and
five is total panic, a rating of three would be very appropriate before and during this
exam. It would indicate that you realize you need to prepare but feel confident about
your ability to do so. A stress level at one or even two would hardly motivate you to
open up the CPNE Study Guide, causing you to come to the exam totally unprepared.
A rating of four or five before and during the exam would inhibit retention of the
content studied as well as paralyze some aspects of your performance.
Four Common Stressors
Over the years, we have observed four common sources of stress associated with the
CPNE. The following is a list of the stressors followed by examples of their causes,
and positive responses you can use to reduce the associated stressor.
• test-taking anxiety
• life change
• ambiguity
• overload
Stressor
Test Taking
Anxiety
Example of Cause
Unfamiliarity
with skills
Positive Response
Refer to the resources listed in this study
guide and practice, practice, practice. Over
preparation with skills and the Areas of
Care will enhance your chances for success
if your stress level increases during the
examination.
III.C.2
Stressor
Example of Cause
Positive Response
Unfamiliar with the
hospital test site
Upon receipt of confirmation, directions
will be enclosed. Do a search on the
Internet. Ask family members or friends
who may know the area. Make appropriate
travel arrangements. Ask the hotel if they
provide a shuttle service to the hospital.
Plan to arrive early on the first day of the
examination.
Test Taking
Anxiety
Unfamiliar with
the equipment
Your CE will orient you to each patient unit
and to any unfamiliar equipment. Speak
up and ask questions. Make sure you are
comfortable using the equipment. Consider
returning a demonstration to the CE.
Test Taking
Anxiety
Failing one or more
of the Simulation
Laboratory Stations
the first evening
Take a deep breath and make sure you
understand your mistake. If you are unclear,
discuss the area of failure with your CA.
Failing the first PCS
Take a deep breath and use your stress
management strategies. While discussing
the point of failure with the CE and CA, ask
questions and clarify. During your break,
regroup use positive self-talk, and set that
failure aside. Remind yourself that you will
have an opportunity to repeat this PCS.
Many students who fail the first PCS pass
the CPNE.
Examiner appears
“cool” and uncaring
The CE’s role is to observe and validate
your performance on the Critical Elements.
In that role, the CE is an objective observer
and is unable to engage you on a personal
level. Try to keep them out of your direct
line of vision. Focus on your patient and the
care you need to give. Seek support from
your CA.
Test Taking
Anxiety
Test Taking
Anxiety
Test Taking
Anxiety
Managing Stress
Stressor
Positive Response
Interruptions
during the PCS
Expect brief interruptions during the PCS.
Use your time wisely. The best thing you
can do is prepare and remain organized
and focused. During the Planning Phase
make a check-list of the Critical Elements
for the Areas of Care assigned. Review your
checklist or organizational plan as you
progress through the PCS. Be flexible. If the
interruption(s) is lengthy, the CE will add the
time to your PCS.
Other
students failing
Adopt a positive outlook. You may see
others “acting out”- there may be tears
from students who have failed a PCS. It is
the role of the CA to assist these students.
Communicating that you care for fellow
students is expected, however, your primary
focus is on you and your performance during
the CPNE. Consider taking breaks alone to
avoid discussions that could increase your
stress level.
Life Change
Preparing to
advance to
the role of a
professional nurse
Along with the positives, there also can
be numerous hurdles to overcome; added
responsibility, role change, possible job
change, leaving co-workers and friends.
Focus on the importance you have placed on
achieving this goal and all of the effort you
have put forth to get this far. Telling friends
and co-workers the date of your CPNE puts
added pressure on you to “pass.” Tell only
those who need to know (e.g., supervisor
and immediate family). Then, surprise the
others with the news of your success.
Ambiguity
Keep a list of your questions. Call the CPNE
office to schedule an appointment to speak
with a nurse faculty member for answers to
Confusion over
interpretation of the your questions. Don’t wait until the day of
the exam to get your questions answered.
Critical Elements
Use the learning resources developed by
Excelsior College (see Unit I).
Test Taking
Anxiety
Test Taking
Anxiety
Example of Cause
III.C.3
III.C.4
Stressor
Overload
Overload
Example of Cause
Positive Response
CPNE study
guide appears
overwhelming
Break apart each unit; read through one
at a time. Concentrate on Units II and IV.
Develop a schedule for each section you are
studying and make an assignment for each
week. Make flash cards for the Areas of Care
and the Critical Elements, or purchase flash
cards or audio CD from Excelsior College’s
LEARN office.
Family and work
commitments
Limit your commitments. It is only for a
short time until you complete the CPNE.
Make preparing for the CPNE a priority for
you now. If it isn’t, postpone your exam
date until you have more time to dedicate
to preparation.
Impact of Stress on Performance
Initially, as your stress increases, so does your performance. In other words, “good” or
low stress enhances your performance. However, there is a range where performance
peaks. Then as stress continues to move towards the high end, your performance
decreases. You become both physically and mentally exhausted.
You may now be asking yourself, “How do I keep myself in the range of peak
performance?” This can be accomplished in two ways: control and predictability. Take
some time now to consider those things within your control during this exam process.
Certainly, you can control the method and amount of time that you spend studying.
The most significant preparation strategy is practicing the Critical Elements under
direct supervision. Postpone your test if you find yourself in a situational crisis. The
overall stress in your life will impact your stress response during the examination.
You can also control when and where you will test by sending your application to the
RPAC of your choice and, depending on availability at that RPAC, securing the best
possible test date for you.
Regarding predictability, information in the CPNE Study Guide can help you to predict
the structure of the exam weekend, including the number of PCSs you will do, the
skills you will perform, and the type of patients for whom you will care. If you take
the time to incorporate measures that will allow you to gain control and predictability
before and during the CPNE, you will significantly increase the likelihood for success.
Managing Stress
III.C.5
Gaining Information
Develop a plan of action
Design a specific time frame for your study. Be sure to include textbook/study guide
reading as well as hands-on skill practice. If you plan to incorporate Excelsior College
learning resources into your study plan, investigate the schedule of offerings so you
can fit them into your study plan.
Develop a skill set
Another way to reduce your stress is to become familiar with and practice each of the
skills listed on the Self Assessment for the CPNE (Appendix J). Once you feel confident
about your performance, be sure to have someone observe you. A registered nurse
is preferred. If one is not available, you can also use a family member or friend. Just
make sure they have the Critical Elements in front of them so they can critique your
performance. Practice until you feel confident of your ability to perform in the clinical
arena under direct supervision. Being watched while performing even the most basic
skill can raise your stress level. Getting accustomed to this ahead of time will allow
you to practice coping with the stress you may feel when the CE observes you during
the PCS.
Decrease the unknowns
If you come across a word, phrase, or skill that is unfamiliar, look it up. Use
fundamentals of nursing, medical-surgical, and pediatric textbooks to enhance your
learning. If you have questions about your understanding of the Critical Elements or
the examination process contact the CPNE office to schedule a telephone appointment
with a faculty member.
Strive to maintain an open and positive outlook during your preparation and
examination. Though it may seem overwhelming, the amount of time and effort you
put into preparation will be beneficial. Keep in mind that you are preparing to pass an
examination that will measure your ability to use critical thinking skills to provide safe
and competent bedside nursing care.
Interventions for Stress Reduction
Identify strategies you have used to control stress in the past. Practice those strategies
and identify new ones that you can use to control your stress response before and
during the examination. The three general categories of response to stress are
physical, behavioral/emotional, and cognitive.
If you tend to react to stress primarily with physical changes, consider one or more of
the following activities that will help you to reduce tension and promote relaxation:
•S
low, deep breathing exercises help to clear your head and increase the
amount of oxygenated blood supply to the brain.
III.C.6
• Meditation and yoga techniques are effective for some people.
•P
hysical exercise is especially helpful while studying. When you are feeling
overwhelmed and exhausted go outside and take a brisk walk. The same can
be done during the exam weekend between each PCS or at the end of the day.
If you tend to react to stress with behavioral or emotional changes, develop a plan of
action to maintain self-control using any or all of the following activities:
•P
ractice time management. Develop a calendar from now until your anticipated
test date that includes “must do” commitments and appointments as well as
regular blocks of time for study.
•B
e assertive; don’t be afraid to say “no” to family or work commitments that
can wait until after you complete the exam.
•K
eep a journal of your thoughts and reactions to your preparation; then reflect
on your entries from time to time.
If you tend to react to stress in a cognitive way such as negative self-talk or
rumination over mistakes, work on developing a positive attitude by using any
or all of the following activities:
•P
ractice positive thinking. Each time a negative thought enters your mind work
quickly to reverse it by using positive self-talk to increase your confidence. Try
saying phrases like “Yes, I can do this!”
•D
iscuss the negative thoughts with a supportive co-worker or friend. Discuss
what strategies might work to help you avoid them.
•K
eep a journal of your thoughts and reactions during your preparation; then
reflect on your entries from time to time.
For extreme stress and anxiety you may need to seek professional assistance.
Remember for every stress response, there is a relaxation response.
Managing Stress
III.C.7
Summary of Strategies for Reducing Stress During the CPNE
Do’s
1. Be prepared. Start to study well in
advance of your examination date.
1. Don’t leave preparation to the last
month before your examination.
2. Prepare in ways that are consistent
with your learning style.
2. Don’t wait until the last minute to
make hotel reservations.
3. Memorize all the Critical Elements
for every Area of Care.
3. Don’t come to the examination
unprepared unless you are
expecting to fail.
4. Expect that your anxiety level will
increase during the CPNE. Plan to
use stress-reducing strategies to
remain focused and calm during the
examination.
4. Don’t focus on other students’
performance during the examination.
Focus only on your performance.
6. Come early to the examination.
5. Don’t be afraid to call the RPAC
to reschedule your examination
if a life crisis occurs within days
of your examination.
7. Arrive at the examination site with a
positive attitude.
6. Don’t take this examination if you
are in a situational crisis.
5. Practice the Critical Elements.
Dont’s
III.C.8
CPNE Last Minute Checklist
Packing for Travel
c C
PNE Study Guide
Carpenito-Moyet’s
Handbook of Nursing
Diagnosis, drug
reference handbook,
and other references
c alarm clock
c p
hoto identification,
black ballpoint pen,
pencil, calculator,
and a watch with a
second hand
c m
ost confident
attitude. Practice the
stress management
techniques you have
identified as most
helpful to you.
c I f you plan to check
your luggage, pack
your uniform and
supplies for the
examination in your
carry-on luggage.
c e
xamination
confirmation
materials. These
materials contain
the time and place
where you meet
the CA.
On Arrival at the
Hotel/Motel
c A
sk for a room
in a quiet area
of the hotel.
c M
ake your next-day
ride reservation to
the test site hospital.
c R
equest a
wake-up call.
The Evening Before
the Examination
c H
elp yourself relax
before going to bed.
Take a hot bath, read
a book, put on your
most comfortable
pajamas, or do
whatever else makes
you feel comfortable.
c R
emind yourself that
you are prepared
and are now ready
to demonstrate your
competence.
c I f the hotel has a
restaurant, inquire if
breakfast is available
at a time convenient
for you (prior to
c Keep well hydrated;
departure for the test
avoid alcohol before
site) on the second
you sleep because
and third day of the
it may interfere with
examination.
the sleep cycle.
c G
et a good night’s
rest. You will be
better able to meet
the demands of the
examination with a
well-rested body
and mind.
c Other
The Morning of
the Examination
c G
et up early to
avoid rushing.
c C
onfirm your
transportation
arrangements to the
test site hospital.
c E at a nutritious
breakfast.
c D
ress in something
comfortable; casual
professional (no
jeans) for Day 1 and
a professional white
uniform and clean
white shoes for Days
2 and 3 of the exam.
(See standards of
professional dress
on page II.A.3.)
c I f you encounter
a delay, notify the
RPAC administrative
office as soon as
possible.
c B
ring your photo
identification,
black ballpoint pen,
calculator, CarpenitoMoyet’s Handbook of
Nursing Diagnosis,
drug reference
handbook, and
a watch with a
second hand.
c Other
IV
Unit IV: Critical Elements
Organizational Content
This unit, separated into sections of study specific to CPNE Areas of Care, provides
a list of the Critical Elements you are to perform during the examination.
Section A: The Planning Phase
Section B: The Implementation Phase
Section C: Clinical Decision Making
Section D: Overriding Areas of Care
Section E: Required Areas of Care
Section F: Selected Areas of Care Related to Assessment
Section G: Selected Areas of Care Related to Management
Section H: Other Selected Areas of Care
Section I:
The Evaluation Phase
Section J:
Simulation Laboratory Stations
In each section/Area of Care you will find the Critical Elements followed by a general
definition and detailed information related to each Critical Element. There are Critical
Thinking/Learning Activities in all sections. Please compare your work with the
answers provided at the end of each section/Area of Care. You should be able to
identify and perform all the Critical Elements within every Area of Care, and be
able use CDM when predicted events in a PCS don’t happen as planned and the
Critical Elements of a PCS need to be modified or omitted.
Suggestions for Study
Plan to work your way sequentially through each section. Practice performing all
Critical Elements in the clinical or simulated setting prior to scheduling the CPNE.
Make arrangements for appropriate supervision when you practice and learn aspects
of nursing care not usually part of your scope of practice. Refer to your fundamentals
of nursing, pediatric, clinical skills and medical-surgical textbooks for established
guidelines for nursing practice. Established Guidelines are the standards of nursing
practice that guide nursing actions.
If you are not licensed as a LPN/LVN we encourage you to make an appointment
to speak with CPNE faculty for suggestions on learning specific nursing skills.
Remember, during the examination you may be asked to perform any of the
Selected Areas of Care.
IV.A.1
UNIT IV
Section A
The Planning Phase
The successful student
1. Writes a Nursing Care Plan that includes
a.Two nursing diagnostic labels selected from a list that are relevant
to the assigned overriding, required, and selected Areas of Care
designated on your PCS Assignment Kardex, one of which must
be an actual patient problem.
b.One projected measurable expected patient outcome for each
nursing diagnostic label, and
c.Two nursing interventions for each nursing diagnostic label, which
will move the patient toward the expected outcome and which are
to be carried out during the PCS.
2. Records the correct flow rate in drops per minute on the Planning
Phase Nursing Care Plan page of the Student PCS Response Form
when a gravity flow administration of parenteral fluid is designated.
Overview of the Planning Phase
The Planning Phase is the period of time in the PCS required for assessment and
planning during which the student writes nursing diagnostic labels, expected
outcomes, and nursing interventions prior to initiating nursing care.
For successful completion of the Planning Phase you are to write a Nursing Care Plan
(NCP) that is congruent with standards of nursing practice and the medical regimen,
as well as calculating the flow rate for a gravity flow IV if assigned. The subsequent
discussion will guide your application of the nursing process in relation to the
expectations of the examination.
The Nursing Care Plan is written on the Planning Phase page of the NCP form, may be
revised during the Implementation Phase, and then evaluated on the Evaluation Phase
page during the Evaluation Phase of the PCS. The NCP form is part of the Student
PCS Response Form (Appendix H). The NCP uses a three-column format: nursing
diagnosis, expected outcome, and nursing interventions. You may use a pencil or
black ink pen to write your nursing care plan.
Plan to purchase either Carpenito-Moyet’s Handbook of Nursing Diagnosis, 11th
edition or Ludwig and Ackley Mosby’s Guide to nursing diagnosis 2006. These are
the only reference for developing your care plan you will be permitted to use during
IV.A.2
the examination. Though you may highlight in your copy, do not write any critical
elements in your book. If you do not bring either of the allowed references when you
take the CPNE, one will be available for your use during the examination.
The Planning Phase is the time during the PCS designated for collecting patient
information, analyzing this data and writing an individualized plan of care. You
will have the opportunity to review the patient’s record including flow sheets and
medication administration records after your CE has reviewed the PCS Assignment
Kardex with you. When you are ready to receive a report for your assigned patient,
your CE will introduce you to the patient’s assigned staff nurse. You will not receive
a report for your first patient on Day 1 of the examination. You will receive this
report the following morning.
On Day 1 of the examination, you will be allowed to take your Student PCS
Response Form with you overnight to write your Nursing Care Plan for PCS #1.
For all other PCSs:
• T
he CE will give you your student PCS response forms and read the Kardex
assignment to you just prior to the actual PCS start time.
• T
he writing of your NCP will be done prior to initiating patient care
(Implementation Phase).
Remember to monitor your time in order to complete an entire PCS in
2-½ hours; time management is your responsibility.
How to Use Your Nursing Diagnosis Guide/Handbook
If you are a beginner at writing Nursing Care Plans, first refer to the Table of Contents
or to the Index to locate your patient’s medical condition and turn to the appropriate
page listed. There you will find a list of nursing diagnoses more commonly associated
with that health problem. Also, read about Nursing Process in your Fundamentals
textbook.
The nursing diagnostic label is the 1st part of a 2- or 3-part nursing diagnosis
statement. The nursing diagnostic label, approved by NANDA, identifies a problem
about a human response to an actual or potential health problem. When choosing a
diagnostic label be sure to validate the correct application by referring to the authors’
note and defining characteristics found in the nursing diagnosis handbook.
The nursing diagnosis statement for an actual problem includes a NANDA approved
label, etiology, and symptoms. The “at risk” nursing diagnosis statement includes a
NANDA approved label and etiology. Because it is only a potential problem, there are
no signs & symptoms. The nursing diagnostic statement should be specific and relate
to the health status of your patient.
The Planning Phase
IV.A.3
Use legally advisable terms when writing the etiology (related to). The etiology should
not reflect a procedure, treatment or person as the cause of the problem. Remember
that the signs and symptoms (defining characteristics) of an actual problem provide
evidence that the problem exists, therefore it needs to support the problem not the
etiology.
Differences Between the Carpenito-Moyet’s Handbook of Nursing Diagnosis
and the Requirements of the CPNE
In the 11th edition of the Handbook of Nursing Diagnosis, you will see that when
using a medical diagnosis as a contributing factor, both “related to” and “secondary
to” are used. For example, activity intolerance related to compromised oxygen
transport system secondary to asthma. Avoid using “secondary to” in your statement.
An acceptable statement would be “activity intolerance related to a compromised
oxygen transport system.”
1. Write a nursing care plan that includes
a.Two nursing diagnostic labels selected from a list that is relevant
to the assigned overriding, required, and selected Areas of Care
designated on your PCS Assignment Kardex, one of which must
be an actual patient problem
For successful completion of the Planning Phase NCP, identify two problems,
one of which designates an actual problem for your assigned patient. The
second problem can be either another actual problem or a problem your patient
is at risk of developing. Write a diagnostic label for each patient problem as part
of the Planning Phase NCP. In addition, for each nursing diagnostic label write a
patient-oriented expected outcome and two nursing interventions which help the
patient move toward that expected outcome. Use the list of nursing diagnostic
labels in either of the allowed references to select the nursing diagnostic labels.
Do not choose a collaborative problem or medical diagnosis as your diagnostic
label. You may choose diagnostic labels that are relevant to the Overriding,
Required, and Selected Areas of Care designated on your PCS Kardex, or relevant
to the patient’s current medical condition. Refer to Maslow’s Hierarchy of Needs
for determining two priority nursing diagnostic labels that reflect the needs of
your patient. The most common priority needs include those on the first and
second levels of Maslow’s Hierarchy. Try to choose nursing diagnostic labels for
your planning care plan that have been and continue to be problems for your
patient.
IV.A.4
An actual nursing diagnosis consists of three parts.
•Actual= diagnostic label + contributing factor (etiology) + signs and symptoms
(defining characteristics)
A risk diagnosis has two parts:
• Risk = diagnostic label + contributing factor (etiology)
It is acceptable to convert an actual nursing diagnostic label to a “risk for” nursing
diagnostic label if it is consistent with the condition of your assigned patient during
the examination. It is not acceptable to convert a NANDA “risk for” label to actual
diagnostic label.
For the Planning Phase of the CPNE, you will be evaluated on the diagnostic label
portion of the nursing diagnosis statement only. However, it is recommended that
you determine the contributing factors and signs and symptoms for the diagnostic
label you identify during the Planning Phase. The “related to” factors serve as
validation that the problem exists or potentially exists for your patient. Signs and
symptoms provide supporting data for an actual problem; they do not exist for a
“risk for” problem.
To formulate a nursing diagnosis collect information from patient record flow sheets,
laboratory results, narrative progress notes, report from the RN, and focus on the
assigned areas of care from the Kardex.
Ask yourself:
•How does this data I have collected compare with what I know about normal
health patterns, human responses to illness, body system physiology and
pathophysiology?
•What are the current signs and symptoms documented for the last 24– 48 hours
in the medical record or on the flow sheets or stated in the report that lead me
to think there is an actual problem?
•What information have I gathered from the nurse’s report about the
patient’s condition and healing process?
•What Areas of Care have I been assigned? What Critical Elements within
the assigned Area of Care would be appropriate nursing interventions for
an actual or “risk for” nursing diagnosis?
The Planning Phase
IV.A.5
Critical Thinking/Application to Practice
1.Which of the following addresses an actual or potential health problem
that can be prevented or resolved by nursing interventions only?
a.
Nursing diagnosis
b.
Nursing assessment
c.
Medical diagnosis
d.
Collaborative problem
2.Which of the following would be an appropriate nursing diagnosis statement for a 2-year-old who has been treated on two separate occasions for
lacerations and contusions due to parental negligence in providing a safe
environment for the child?
a.
High Risk for injury related to abusive parents
b.
Injury, Risk for, related to impaired home maintenance
c.
Child Abuse related to unsafe home environment
d.
Risk for Injury related to unsafe home environment
3.Place check marks next to the nursing diagnosis statements that are written
correctly and identify the errors in the incorrect diagnoses.
a.Impaired Skin Integrity related to mobility deficit as evidenced
by ulcer on right heel.
_________________________________________________________________________
_________________________________________________________________________
b.
Nausea and vomiting related to medication side effects.
_________________________________________________________________________
_________________________________________________________________________
c.Impaired gas exchange related to altered oxygen transport as
evidenced by oxygen saturation of 90% on room air.
_________________________________________________________________________
_________________________________________________________________________
d.
Needs assistance walking to bathroom: related to immobility.
_________________________________________________________________________
_________________________________________________________________________
IV.A.6
A Nursing Care Plan Case Example:
The patient is an 8-year-old who recently underwent an appendectomy.
The patient has
• An abdominal midline incision
• An abdominal drain to bulb suction
• An IV of D5W @ 50 ml/hrs
• A reluctance to deep breathe and cough
• Morphine Sulfate ordered for pain
• Rated pain level at 4 on a 0−5 faces scale
Think about the possible nursing diagnostic labels associated with the signs and
symptoms for the above patient information. Are there aspects present in this
patient’s clinical condition which warrant monitoring and prevention that could
lead you to an actual or potential health problem? What might the patient see as
issues that need to be addressed to promote the healing process?
An actual problem for the above patient is pain. The diagnostic label from
Carpenito-Moyet or Ladwig and Ackley that describes this problem is Acute
Pain. In this case the related factor (R/T) includes the patient has an abdominal
surgical incision. The patient’s report of a pain level of four on a scale of 0– 5
validates this is an actual problem for the patient. The actual diagnosis would be
written as follows:
Actual diagnosis
Acute Pain + related to (R/T) surgical incision + as evidenced by (AEB)
pain level of 4 on a 0−5 faces scale for children
(Diagnostic label) + (related factor) + (signs and symptoms)
Since this 8-year-old is reluctant to deep breathe and cough, a potential problem
with respiratory status may exist. While 8-year-olds usually have no problems
with respiratory status, this patient is post-operative and reluctant to perform
required respiratory hygiene activities because of pain. Based on the possible
effects of anesthesia on the lungs a potential problem exists for this patient.
The nursing diagnostic label found in the appropriate references indicate that
a potential problem could be Ineffective Breathing Pattern. The related factor
would be the patient’s pain. The risk diagnosis would be written as follows:
Risk diagnosis
Risk for Ineffective Breathing Pattern + related to pain
(Diagnostic label) + (related factors)
The Planning Phase
IV.A.7
4.
Develop an Actual diagnosis and a Risk diagnosis for the following patient.
A 60-year-old male patient, 2 days s/p right total hip replacement.
Your assignment includes:
• A regular diet
• T
ransfer to chair for lunch, right toe touch only during ambulation,
abductor pillow between legs while in bed
• Codeine po for pain
• Dressing change to right hip
Actual diagnosis
_________________________________________________________________________
Risk diagnosis
_________________________________________________________________________
b.One measurable expected patient outcome for each nursing
diagnostic label.
Write one measurable patient expected outcome for each diagnostic label.
The patient’s progress towards the expected outcome established during the
Planning Phase will be evaluated after care is implemented. The outcome
statement is the benchmark you will use to evaluate the patient’s progress
in resolving the problem. For example, an outcome statement (or benchmark)
could be “The patient will report a pain level of less than 3 on a pain scale of
0−10 during the PCS.”
Formulating an outcome statement for my assigned patient
• O
utcome formulation should be directed toward resolving the patient
problem or preventing a problem. For example: “ Patient will report
relief of pain ½ hour after pain medication is given by stating pain level
is 3 or less on a scale of 0−10.” Your outcome statement should include
a measurable patient behavior that can be evaluated in relation to the
achievement of the outcome.
• P
lease note that the outcomes may be taken from either of the approved
references; however, outcomes should be specifically tailored to fit your
patient’s situation. Please note that the outcome stated in both CarpenitoMoyet and Ladwig and Ackley are generally very broad in nature, and
may need changes to meet specific needs of your patient. Use your
nursing knowledge when developing the patient centered goal/outcome.
IV.A.8
• A
n outcome statement provides direction for planning the interventions,
serves as a benchmark for evaluating patient progress, and enables the
patient and nurse to determine when the problem is solved. To be useful
the patient outcome should reflect the following criteria:
1.
Clearly stated
2.
Realistic and safe
3.
Acceptable to the patient and/or family
4.
Written in terms that are “patient centered”
5.Specific and concrete, directly observable by seeing, hearing,
and/or feeling
5.
Rate the following outcomes: M = meets criteria, D = does not meet criteria
Expected Patient Outcomes During PCS:
M
D
1. Patient will ambulate to door using crutches.
2. Patient will correctly demonstrate use of Incentive Spirometer.
3. Understand the benefits of a low sodium diet.
4. Nurse will encourage patient to increase daily activity.
6.Rewrite the following outcome statements so they accurately reflect
the above criteria.
a.
Control diarrhea.
_________________________________________________________________________
b.
Ambulate the length of the unit 1 time.
_________________________________________________________________________
c.
Be pain-free.
_________________________________________________________________________
d.
Assist to the bathroom.
_________________________________________________________________________
The Planning Phase
IV.A.9
c.Two nursing interventions for each nursing diagnostic label which
will move the patient toward the expected outcome which can be
carried out during the PCS.
During the Planning Phase you will be required to write two nursing interventions which will help to move the patient toward the expected outcome.
In addition you will be expected to carry out all of the interventions that you
write as part of you NCP. Therefore you must be sure the interventions you
write can be implemented during your PCS.
It will be helpful to write the interventions as specific, separate actions so they
will direct the nursing care you provide during the PCS. An example of a specific
action is, “Ask the patient to cough and deep breathe once during the PCS.”
An example of an action that lacks specificity is, “Tell the patient to remember
to cough and deep breathe.” The interventions are to be implemented and the
effectiveness evaluated by you during the PCS. Therefore, ask yourself: “Will I
be able to evaluate the effectiveness of the interventions and will the examiner
know when I’m performing the interventions based on what is written on my
Planning Phase Nursing Care Plan?”
Writing Nursing Interventions
• N
ursing interventions should be single actions that are directly related
to achieving the stated outcome and that are to be performed during the
PCS. For example: The interventions “reposition the patient once during
PCS” and “ encourage the patient to drink at least 12 oz. of fluid during
the PCS” promote achievement of the outcome “skin will remain free of
breakdown.”
• Interventions may be taken from Carpenito-Moyet or Ladwig and Ackley;
however, such interventions should be tailored to fit your patient’s
situation and directly related to achieving the patient outcome. You are
encouraged to write an intervention in your own words drawing upon
your nursing knowledge.
• V
iew your interventions and outcomes in an “If…then…relationship.” You
might say to yourself, for example “If I perform these interventions, then
the patient will achieve the stated outcomes.” The intervention should be:
1.
Specific and adhere to medical regime.
2.
Realistic and safe.
3.Appropriate to the nursing diagnostic label and expected
outcome written for the patient.
4.
Consistent with standards of practice.
5.
Consistent with legal and ethical standards.
6.
Linked to the assigned Areas of Care.
7.
Implemented during the PCS.
8.
Age-appropriate.
IV.A.10
Assessment interventions are designed to monitor the patient (e.g., assess breath
sounds). Interventions that help a patient achieve a goal (e.g., instruct patient
to perform deep breathing and coughing exercises) are designed to impact a
problem or etiology of a problem. Therefore, we encourage you to write at least
one intervention per nursing diagnosis that is not assessment related.
Nursing interventions, such as requesting a referral, that require others to
follow up are difficult to evaluate for an immediate impact toward achieving
the identified outcomes and, therefore should be avoided.
7.Rate the specificity of the following interventions.
S = specific, NS = not specific
Nursing Intervention
S
NS
1. Administer the ordered analgesic during the PCS.
2. Reduce patient’s fear of taking analgesics
3. Assess dressing for wound drainage
4. Maintain asepsis
Steps to develop a Nursing Care Plan
1.Review the PCS Assignment Kardex. Identify Areas of Care assigned.
Determine Nursing actions (Critical Elements) to be implemented.
2.Review the patent’s record; collect baseline assessment data related
to the assigned Areas of Care and the patient’s clinical condition.
3.Identify actual or potential patient problems.
4.Choose a diagnostic label from the handbook that represents the
problem identified; do not use a collaborative problem.
5.Use your nursing knowledge in addition to referring to your Handbook
to identify expected outcomes and nursing interventions.
6.
7.Write interventions that can be completed and evaluated during
the PCS.
Write expected outcomes according to criteria.
8.Review the PCS Assignment Kardex for Cindy Burns, on the following page
and complete the Planning Phase NCP that follows.
The Planning Phase
IV.A.11
Sample
1315
Appendicitis
2 days ago
Appendectomy
1045
Cindy Burns
6225
8 years
705312
Morphine Sulfate IVP prn for pain.
Pt. unable to cough, output J.P. drain > 50 ml per day.
√
x 2 upper
Susan Murphy
none known
√
Post op day #2
√
√
√
*
√
*
oral
√
√
√
D5W
50 ml/hr
√
√
√
√
with 1 person assist x 1
during PCS
√
√
√
**
Incentive
Spirometer x 5-10 repetitions
**ask RN to
√
medicate prior to
dressing change
Dry sterile dressing
to abdominal drain wound site
**
Abdominal drain to
Jackson Pratt bulb suction
√
√
**
faces scale
IV.A.12
The Planning Phase
IV.A.13
Criteria for Acceptance of the Nursing Care Plan
Acceptance of the NCP by the CE means that you have prepared a plan based on the
available information, and have met the Critical Elements for the Planning Phase.
Entering the Implementation Phase is contingent upon successfully completing the
Planning Phase. To meet all Critical Elements for the Planning Phase record the
correct flow rate in drops per minute when a gravity flow IV is assigned.
You will not be able to enter the Implementation Phase until the CE has reviewed and
accepted the Planning Phase NCP. Once the NCP is evaluated and accepted including
a correct calculation of the flow rate for a gravity flow primary IV, the CE will say,
“You have met the Critical Elements for the Planning Phase and are now ready to
enter the Implementation Phase. All the overriding, required, and selected areas of
care are now in effect.”
Examples of unacceptable aspects of a Planning Phase NCP are as follows:
•You write “force fluids” as a nursing intervention for a patient on restricted
fluids; this violates safe nursing practice and the medical regimen, and
therefore the Critical Element is failed.
• You write “OOB to chair” when the patient is on bed rest.
•You omit writing one outcome and/or any interventions with your nursing
diagnostic label.
•You use a medical diagnosis as a nursing diagnostic label such as “infection.”
Infection is a medical diagnosis and is not acceptable as a diagnostic label
(patient problem).
If a failure occurs during the Planning Phase, the PCS will be terminated at that point.
You will then wait for your clinical examiner to be available for your next PCS to
begin unless this failure results in the termination of the CPNE.
IV.A.14
2. Record the correct flow rate in drops per minute on the Planning Phase
Nursing Care Plan page of the Student PCS Response Form when a
gravity flow administration of parenteral fluids is designated.
Calculate the correct drops per minute to be infused when a gravity flow IV is
assigned. The CE will write on the PCS Assignment Kardex under the area of
Fluid Management, the IV hourly rate of flow in ml/hr and the drop factor for the
specific tubing being used
You will not have to calculate the drops per minute when the patient is receiving
primary parenteral fluids via an infusion control device. Criteria for evaluating
student behaviors with infusion control devices is discussed in the section
addressing the Fluid Management Area of Care.
Gravity Flow IV Rate Calculation:
Flow rate (gtt/min) =
Volume to be administered (ml) × drop factor of the tubing (gtt/ml)
Time to be administered (Minutes)
9.Patient is ordered to receive 150 ml D5 ½ NS per hour. IV tubing gtt factor
is 10 gtt ml. Calculate the gravity flow rate in gtts /min.
_________________________________________________________________________
_________________________________________________________________________
10.After reviewing the following three Kardexes, develop a Planning Phase
NCP for each situation. Include:
•T
wo projected nursing diagnostic labels related to the assigned areas
of care. (We encourage you to include the etiology (R/T) and signs
and symptoms).
•O
ne patient-centered expected, measurable outcome for each nursing
diagnostic label.
• Two specific nursing interventions for each diagnosis that:
ill move the patient toward the expected outcome.
W
Can be carried out during the PCS.
• A calculation of your IV flow rate in drops per minute if required.
The Planning Phase
IV.A.15
1
0730
Jean Kaffman
802
10/19/58
Lortab 5 mg for pain
Has a weak cough
√
1000
Degenerative Joint Disease
Post op day #2
2 days ago
Right total knee replacement
Female
127650
Tameka James
x2
*
√
√
√
eye
glasses
√
*
oral
digital
√
√
√
D5 LR
√
75 ml/hr
√
10 gtt/ml
√
√
report to assigned
nurse if
< 92%
√
√
√
walker; weight bearing
with one assist
√
√
√
√
TED stockings
Regular
√
√
√
**
Incentive
Spirometer x 10 repetitions
**
√
√
**
0830 L
ovenox 30 mg Subq
(do not expel air;
administer in abdomen)
0830 Multivitamin ÷ tab PO
√
√
**
Right leg
CPM
flexion 10-45 °; extension 0-10°
10 cycles/min while in bed
√
ice bag continuously to right knee
IV.A.16
The Planning Phase
IV.A.17
2
1100
Will O’Brien
5432
3/6/39
has triple lumen catheter
Receiving IV antibiotics; has oral thrush,
c/o poor nights sleep
√
x2
1330
Left lower lobe Pneumonia, COPD
2 days ago
Male
678910
Nadine
√
Cleocin
√
*
√
√
eye glasses
√
*
√
oral
digital
√
D5 W –c
20 meq
Potassium Chloride
125 ml/hr
√
√
√
√
√
√
√
self
X 1 during PCS
√
√
√
Regular
√
√
√
**
Incentive
**
Beclovent Multidose Inhaler
2 puffs
1200
Atrovent Multidose Inhaler
2 puffs
1200
Nystatin 100,000 units (1 ml) po
swish and swallow 1200
√
√
√
**
2 liters/min
report to
nurse if 92% or less
**
medications
IV.A.18
The Planning Phase
IV.A.19
3
1000
Ruptured Appendix
3 days ago
Appendectomy
POD #3
John
0730
Carlos Lopez
male
510A
1/6/2000
123456
tylenol –c codeine ordered for pain.
√
x2
√
o known
n
allergies
*
√
√
√
√
3 days ago
*
temporal
√
D5 ½ NS
–c 20 meq
Potassium Chloride
80 ml/hr
√
15 gtt/ml
√
√
√
√
√
√
√
√
with one person x1 during PCS
√
√
**
clear liquids
√
√
√
**
Incentive
**
√
wet to moist Normal
Saline drsg, pack surgical
incision
cover with DSD
**
Ampicillin 450 mg in
50 ml D5W
Infuse over 30 minutes
√
15 gtt/ml
IV.A.20
The Planning Phase
IV.A.21
Critical Thinking Answer Key
Planning Phase
1.Which of the following is an actual or potential health problem that can be
prevented or resolved by nursing interventions only?
[a] Nursing diagnosis
2.Which of the following would be an appropriate nursing diagnosis for a
2-year-old who has been treated on two separate occasions for lacerations
and contusions due to parental negligence in providing a safe environment
for the child?
[d] Risk for Injury related to unsafe home environment
3.Place check marks next to the nursing diagnoses that are written correctly
and identify the errors in the incorrect diagnoses.
[a] & [c] are correct as written, [b] does not have evidence for an actual problem
and [d] is written as a need. Correct statement for [b] = Nausea R/T medication
side effects as manifested by pt’s complaints. Correct statement for [d] = Mobility
Impaired R/T muscle weakness as manifested by unsteady gate requiring assistance.
4. Develop an Actual diagnosis and a Risk diagnosis for the following patient:
A 60-year-old male patient, 2 days s/p right total hip replacement. Your
assignment includes a regular diet, transfer to chair for lunch, toe touch only.
Abductor pillow between legs while in bed, Codeine PO for pain, and dressing
change to right hip.
[a] acute pain R/T tissue trauma AEB by pt’s grimacing and verbalizing pain.
Risk for injury: fall R/T altered mobility.
5. Rate the following outcomes: M = meets criteria, D = does not meet criteria
Expected Patient Outcomes During PCS:
1. Patient will ambulate to door using crutches.
2. Patient will correctly demonstrate use of incentive Spirometer.
3. Understand the benefits of a low sodium diet.
4. Nurse will encourage patient to increase daily activity.
M
M
M
D
D
D
IV.A.22
6. Rewrite the following outcome statements correctly using the above criteria.
a.
Control diarrhea.
Patient will report less diarrhea.
Ambulate the length of the unit 1 time.
b.
Patient will ambulate the length of the unit x1.
Be pain-free.
c.
Patient will verbalize a pain level of “0” on a 0-5 scale.
Assist to the bathroom.
d.
Patient will ambulate to the bathroom with one assistant.
7.Rate the specificity of the following interventions.
S = specific, NS = not specific
Nursing Intervention
1. Administer the ordered analgesic during the PCS.
S
S
NS
2. Reduce patient’s fear of taking analgesics
3. Assess dressing for wound drainage
NS
S
NS
4. Maintain asepsis
8.Review the PCS Assignment Kardex for Cindy Burns, 8-year-old female,
hospitalized status post appendectomy and complete the patient NCP
on the following page.
The Planning Phase
Critical Thinking Answer Key #8 (example):
Acute Pain [R/T tissue trauma AEB
complaint and grimacing]
Cindy Burns
report pain at or < 3 on 0-10 scale
within 30 minutes of pain relief
measures
Offer distraction of paper and
pencil for drawing.
Ask staff RN to medicate patient
for pain as needed.
Note: only diagnostic label will
be scored in the Planning Phase.
Ineffective airway clearance
[R/T patient’s inability to cough
AEB abnormal
IV.A.23
demonstrate effective cough
Instruct patient to forcibly cough
p– 3 deep breaths
during PCS
lung sounds bilateral lower lobes.]
Instruct patient to use Incentive
9. F
low rate (gtt/min) = Volume to be administered (ml) X drop factor of the tubing
(gtt/ml)
25 gtts/min
10. Develop a Planning Phase NCP for each of the following situations.
Include:
•T
wo projected nursing diagnostic labels related to the assigned areas
of care. (We encourage you to include the contributing factor and signs
and symptoms).
•O
ne patient-centered expected, measurable outcome for each nursing
diagnostic label.
•T
wo nursing interventions for each diagnosis that will move the patient
toward the expected outcome and can be carried out during the PCS.
• A calculation of your IV flow rate in drops per minute if required.
* See sample NCPs
IV.A.24
Critical Thinking Answer Key #10:
PCS #1 Jean Kaffman
Instruct patient to cough forcefully
Ineffective airway clearance [R/T
retained secretions AEB abnormal
breath sounds]
have clear breath sounds after
respiratory hygiene activities.
after 3 deep breaths
Note: only diagnostic label
will be scored in the Planning
Phase.
Impaired physical mobility
[R/T tissue trauma AEB need for
assistance getting OOB]
Provide non-skid footwear
demonstrate increased strength
and endurance.
Assist patient with use of walker
when ambulating to bathroom.
Phase.
13
Critical Thinking Answer Key #10 (continued):
Altered oral mucous membranes
[R/T oral thrush AEB cracked
tongue]
PCS #2 Will O’Brien
demonstrate techniques to restore
integrity of oral mucosa
Instruct patient to swish Nystatin
around mouth before swallowing
Phase.
Fatigue [R/T sleep disturbance AEB
complaints of feeling tired]
Phase.
Teach patient to rinse mouth post
inhaler use
report feeling less tired
Organize care to allow patient
to nap after lunch
Elicit the patient’s preferences in the
organization of care
The Planning Phase
Critical Thinking Answer Key #10 (continued):
IV.A.25
PCS #3 Carlos Lopez
Teach patient to splint abdomen
Acute Pain [R/T tissue trauma
demonstrate ways to decrease
AEB grimacing with movement]
discomfort when moving
Reposition patient
Anxiety [R/T hospitalization
experience AEB restlessness]
demonstrate less restlessness
Ask questions to elicit expression
of feelings about hospitalization
Provide distraction activities
of cartoon on TV.
20
IV.A.26
IV.B.1
UNIT IV
Section B
Implementation Phase
Implementing your Nursing Care Plan
During the Implementation Phase, your plan of care will be put into action. You are
expected to implement the nursing interventions you have identified appropriate for
resolving your patient’s problem and meeting his or her health care needs in addition
to implementing the Critical Elements within the Required, Overriding, and Selected
Areas Of Care assigned.
Nurses use their clinical decision-making skills by modifying or changing their
established plan of care in response to the clinical data they collect while caring
for their patients.
•A
s a nursing student, during your Implementation Phase of providing care
to your assigned patient, you may choose to revise your NCP.
• If you choose to revise your diagnostic label (problem), expected outcome,
or planned interventions during the Implementation Phase, the changes
need to be written on the Revised Nursing Care Plan page of the PCS response
form and shown to the CE to verify consistency with what is acceptable for a
NCP in the Planning Phase.
Possible examples of changes in the plan of care are as follows:
•Y
our patient’s nursing diagnostic label is “Acute Pain.” Your patient rates pain
as 0 on a scale of 0-10 and states that the problem that was responsible for
the pain has been resolved. You would change the diagnosis to “Risk for Acute
Pain” and evaluate your interventions for appropriateness.
•Y
our stated intervention is, “Assist the patient to splint incision while coughing
and deep breathing.” You note the patient is already performing this without
any action on your part. You also assess that the patient needs direction to use
the incentive spirometer correctly and you proceed to verbalize this to CE.
You review the use of the incentive spirometer with the patient. You would
write this intervention on your revised NCP, and in your narrative notes during
the Evaluation Phase.
IV.B.2
Timed Critical Elements
There are timed Critical Elements for certain Areas of Care that need to be completed
within 20 minutes of beginning the Implementation Phase.
The CE will write the time the Implementation Phase begins on your PCS form after
reading the statement, “You have met all the Critical Elements for the Planning Phase
and are now ready to enter the Implementation Phase. All Critical Elements for
Overriding Required and Selected Areas of Care are now in effect.”
The following Areas of Care have timed Critical Elements:
• Caring
• Fluid Management
• Enteral Feeding
IV.C.1
UNIT IV
Section C
Clinical Decision Making (CDM)
Definition
CDM is a problem-solving process by which choices are made in nursing
practice. This process involves the identification of patient problems,
selection of a course of action or nursing intervention, and evaluation
of a patient’s progression response based on theory, scientific principles,
established protocols, and pertinent references.
Utilizing CDM
CDM is a powerful tool when used during the CPNE. As in any clinical situation,
sometimes events happen to change the plan that you set out to complete. Whenever
this happens during the testing situation, you will be required to verbalize your
thought processes. In most testing situations events occur as planned; however, the
option to invoke CDM provides some flexibility for variations that occur in the clinical
setting. Remember that appropriate or sound clinical decisions are made based on
nursing theory and accepted safe standards of practice. Whenever the predicted
events of a PCS don’t happen as planned and the Critical Elements of the examination
need to be modified or omitted, you are to use Clinical Decision Making.
Competence in Clinical Decision Making is essential for nursing practice. Members
of the health disciplines use a distinct body of knowledge when making decisions
that affect patients. Nursing students develop the knowledge and skills essential
for clinical judgment when caring for patients. Developing and utilizing critical
thinking skills is essential. Nurses are faced with an abundance of information that
must be interpreted and weighed against standards of practice prior to making a
clinical decision. In many circumstances that decision must be made in a relatively
short period of time and with someone’s life dependent on it. Assimilation of the
information through critical thinking will assist you in making appropriate and quick
clinical decisions.
IV.C.2
Case Study
You have received a report from the patient’s assigned staff nurse, who
indicates that your 14-year-old patient is doing well after an open reduction
and internal fixation of a fractured left femur. The patient has been in
traction for 6 weeks and a cast was applied yesterday. Your assignment
includes ambulating the patient without weight bearing on the left leg.
After standing with the aid of a walker, the patient tells you, “I don’t feel
good. I’m dizzy and feel like I’m going to vomit.”
Even though the PCS assignment designated ambulation, you clinical
decision would be to omit this activity because of the change in the patient’s
condition. You are to verbalize to the CE your intent to omit this activity and
your rationale for doing so.
You say, “I will not ambulate the patient as assigned because of the patient’s
dizziness and nausea.” You assist the patient back to bed, obtain vital signs,
and immediately report your findings to the assigned staff nurse.
Evaluating CDM
Clinical Decision Making is demonstrated in the CPNE during all phases of the
nursing process. Clinical Decision Making is assessed continuously throughout each
PCS. In the Implementation Phase, clinical decisions are observed throughout your
implementation of Critical Elements. When you make a deliberate decision to omit
or modify a Critical Element, your reason for the omission or modification should be
verbalized to the Clinical Examiner prior to the time of the omission or modification.
The Clinical Examiner will determine the acceptability of your decision and consult
with the CA to discuss the circumstances surrounding any questionable decision.
An incorrect decision will result in a failure of the PCS.
Clinical Decision Making is an end point of critical thinking that leads to problem
resolution. Clinical judgment is used to make that decision based on nursing theory
and principles.
Clinical Decision Making is evaluated throughout all phases of the CPNE. Clinical
decisions that place your patient at risk for Physical or Emotional Jeopardy would not
be acceptable as part of safe nursing practice and therefore would not be acceptable
as part of the CPNE. Clinical Decision Making is used during the examination to allow
for alterations or omissions of Critical Elements in response to changes that occur
within a PCS.
IV.D
UNIT IV
Section D
Asepsis
Caring
Emotional Jeopardy
Mobility
Physical Jeopardy
Overriding Areas of Care encompass all nursing competencies and are evaluated
in all aspects of nursing care throughout every PCS. During each PCS, your actions
should ensure patient safety and comfort, as well as promote positive physical and
emotional well-being. You will be expected to establish a professional relationship
with your patient built on trust and respect for values, dignity, and culture.
IV.D.1.a
UNIT IV
Section D.1
Asepsis
Critical Elements for Asepsis
1. Washes hands in the presence of the Clinical Examiner before
beginning the Implementation Phase of each PCS
2. Protects self, others, and the environment from contamination
3. Protects the patient from contamination
4. Disposes of contaminated material in the designated container(s)
5. Establishes a sterile field when required
Asepsis is the prevention of the introduction and/or transfer of microorganisms. Special consideration should be given to hand washing before,
during, and after each PCS as required by the principles of asepsis. Any time
a violation of asepsis occurs, the entire PCS will be terminated and failed.
Asepsis is evaluated during all phases of the examination. You are to apply the
principles of asepsis during your performance of all Critical Elements in each PCS.
This Area of Care encompasses medical and surgical asepsis as well as Standard
Precautions. During the examination, you will be expected to wash your hands before
beginning Implementation and at other times during the PCS with soap, water, and
friction or alcohol-based cleansers. You are expected to use a barrier when turning off
the water after washing your hands. You are to protect yourself and your patient from
contamination throughout every PCS. In addition, you will be required to dispose of
contaminated materials in the designated container(s). If you are assigned an Area of
Care for which setting up a sterile field is required, your application of the principles
of surgical asepsis will be evaluated using the Critical Elements for Asepsis.
Your assignment may include caring for patients requiring complete or partial
isolation (e.g., contact precautions). Isolation technique is evaluated according to
the Critical Elements within the Overriding Area of Care Asepsis.
IV.D.1.b
Latex Allergy:
Contact the Disability Services Coordinator to request accommodation for
the testing situation if you have a known or suspected latex sensitivity/
allergy (refer to II.C.6).
1.Washes hands in the presence of the Clinical Examiner before beginning
the Implementation Phase of each PCS.
Wash your hands in view of the CE at the beginning of the Implementation
Phase. During orientation to the patient care unit, the CE will point out the
location of sinks. Inform your CE when you are ready to wash you hands and
be sure that your CE observes your performance. The established guidelines for
hand washing during the CPNE are those set by the Centers for Disease Control.
According to the CDC Guidelines for Hand Hygiene in Healthcare Settings (2002),
routine hand washing is a vigorous rubbing together of all surfaces of lathered
hands for at least 15 seconds, followed by thorough rinsing under a stream of
water or the use of an alcohol-based (waterless) hand rub. Plain soap or alcoholbased hand rub should be used unless otherwise indicated. Not using soap or
an alcohol-based hand rub would be a point of failure. Your CE will not time
the duration of your hand washing. Remember to turn faucets off using a barrier
such as a paper towel.
If you should initiate the Implementation Phase of the examination by
performing any Critical Element within an Overriding, Required, or Selected
Area of Care without having washed your hands, your examination will be
terminated for a violation of this first Critical Element. The only exception to
this rule is Caring Critical Element #1. The distinction is that “greeting” occurs
spontaneously and is socially expected upon entering a room.
Case Study
If you enter your patient’s room, greet the patient, and decide to
begin to verify the accuracy of the flow rate of the patient’s IV without
washing your hands, you will have violated the first Critical Element
of Asepsis. You should wash your hands after the Planning Phase
is over and before you begin to perform Critical Elements in the
Implementation Phase.
Throughout the PCS, you will be expected to protect yourself, others, and the
environment from contamination. You are expected to decide when and whether
it is necessary to use personal protective equipment (PPE). PPE includes any
equipment the nurse can wear for protection from exposure to blood or body
fluids; e.g., gowns, masks, goggles, or gloves. During the orientation to the
Overriding Areas of Care –Asepsis
IV.D.1.c
patient care unit, the CE will point out where clean gloves and other PPE items
are kept. Latex-free gloves will be provided upon your request. You are expected
to wear gloves whenever there is any risk for exposure to blood or body fluids.
For example, administering medications via injection places you at risk for
coming into contact with the patient’s blood if any bleeding occurs as you
withdraw the needle.
Using personal protective equipment (PPE) is one example of the work practice
controls evaluated during the CPNE. Work practice controls are actions the
health care worker can take to reduce risk of exposure to blood or body fluids;
e.g., never recapping contaminated needles, disposing of used needles in sharps
containers, and washing hands. Remember to consider protecting yourself at
all times when choosing actions to take during the CPNE. If you neglect to take
these protective precautions, the CE will stop you before contamination occurs.
Consequently the PCS would be failed under Asepsis.
Protecting the patient from contamination is also required during the CPNE;
it is essential that you do so to prevent the spread of nosocomial infections.
An example of protecting the patient from contamination is using a barrier on
the balancing portion and the platform of the scale when weighing an infant
or child. If the scale becomes soiled while being used, it must be washed after
use to maintain asepsis. During the orientation to the patient care unit, the
CE will point out the location of the barriers placed on the scale when
weighing a patient.
Hand washing will be expected throughout the PCS as a means to protect
yourself and your patient from contamination. Think about the occasions
when you should wash your hands. Should you wash them:
• Before you touch your patient and/or your patient’s equipment?
• After you handle contaminated materials?
• Between patients?
• Before you don gloves?
• After you take off gloves?
• Prior to entering a clean area such as the medication cart or room?
While the above list is not exhaustive, it suggests situations to consider when
deciding whether you should wash your hands. When in doubt, wash your
hands. Think about the nursing actions that you are about to perform. Consider
what you were doing with your hands just prior to performing this action.
Determine whether your hands are clean or dirty.
IV.D.1.d
Case Study
You have just given the patient an injection. Take your gloves off and
wash your hands before writing on your Student PCS Response Form
and MAR. This will minimize the spread of microorganisms from the
patient’s room to you and other areas of the patient unit.
1. For the following nursing actions, decide whether you should wear gloves
and when you would need to wash your hands.
Action
Requires
Gloves
(yes/no)
When to Wash Hands
Obtaining a blood specimen
Assessing an IV site
Providing a backrub
Removing an abdominal dressing
Taking an oral temperature
Preparing an oral medication
at the medicine cart
2. Think about when and how you use the CDC Guidelines for Standard
Precautions. What personal protective equipment (PPE) and/or work
practice controls would you use in the following situations? What steps
would you take to protect yourself?
Situation
PPE Used
Steps Taken to Protect Yourself
Measuring urinary output for a
patient on diuretic therapy
Changing an abdominal
dressing for a patient on contact
precautions
Weighing an infant on the
pediatric unit scale
Picking up your pen after it falls
on the floor
Going to the medication cart
to prepare medications after
completing vital signs
Entering the room of a patient
on respiratory precautions
Changing an infant’s wet diaper
Situation
PPE Used
IV.D.1.e
Feeding an infant who has
RSV and is on enteric secretion
precautions
Suctioning a tracheostomy
Changing a colostomy appliance
Bulb suctioning an infant’s nares
Irrigating a feeding tube
You will be expected to dispose of contaminated materials, including dressings,
in a designated container on the patient care unit. During the orientation to the
patient care unit, the CE will point out the location of the designated containers.
5. Establishes a sterile field when required
In situations where sterile technique is necessary, you will be required to
establish and maintain a sterile field. You may decide which type of sterile field
to use depending on the task and the equipment available. For example, a wet
to moist dressing on a large abdominal wound would require a sterile
impermeable barrier to prevent contamination of the sterile dressing. Wet
dressing supplies can be prepared in a sterile basin or on an impermeable
barrier. A simple dry sterile dressing change may not require a sterile field setup.
The packaging of the dressing materials may be used for the sterile field.
IV.D.1.f
Asepsis
1. For the following nursing actions, decide whether you should wear gloves
and when you would need to wash your hands.
Action
Requires
Gloves
(yes/no)
When to Wash Hands
Obtaining a blood specimen
Yes
Before donning and after removing gloves.
Assessing an IV site
Yes
Before donning clean gloves and
after removing soiled gloves.
Providing a back rub
No
Before you start your care.
Removing an abdominal dressing
Yes
after removing soiled gloves at the
end of the procedure.
Taking an oral temperature
Yes
after removing soiled gloves.
Preparing an oral medication
at the medicine cart
No
Before preparing medication.
2. Think about when and how you use the CDC Guidelines for Standard
Precautions. What personal protective equipment (PPE) and/or work
practice controls would you use in the following situations?
Situation
Measuring urinary output for a
patient on diuretic therapy
Changing an abdominal
dressing for a patient on contact
precautions
Weighing an infant on the
pediatric unit scale
PPE Used
Gloves
Wash marked patient container to
measure output. Wash hands before
gloving and after removing gloves.
Gloves
and gown
Wash hands prior to gloving, wear
gown and dispose of dressing material
in designated material, remove gloves
and gown, wash hands.
Gloves
and barrier
for scale
Wash hands before donning gloves,
place barrier on scale, remove soiled
diaper, place soiled diaper in appropriate receptacle. Discard barrier. Remove
soiled gloves when procedure is complete then wash hands.
Picking up your pen after it falls
on the floor
Hand
and pen
washing
Wash hands and pen with soap
and water.
Going to the medication cart
to prepare medications after
completing vital signs
Hand
washing
Wash hands after completing vital
signs before leaving patient’s room.
Situation
Entering the room of a patient
on respiratory precautions
Mask
and hand
washing
Wash hands and don mask.
Gloves
Wash hands prior to gloving. Change
diaper, place in appropriate receptacle.
Remove gloves, wash hands.
Feeding an infant who has
RSV and is on enteric secretion
precautions
Gloves
and gown
Wash hands, put on gown, gloves and
put on mask. After returning infant to
crib remove gloves and gown, placing
them in appropriate receptacles.
Wash hands.
Suctioning a tracheostomy
Gloves,
gown,
mask,
protective
eyewear
Wash hands, put on mask, protective
eyewear/face shield, and gown, put on
gloves. After suctioning, remove gloves,
wash hands. Remove mask, gown and
protective eyewear/face shield. Wash
hands.
Changing a colostomy appliance
Gloves
Wash hands prior to gloving. Dispose
of appliance in appropriate receptacle.
Remove gloves, dispose of in appropriate receptacle. Wash hands.
Bulb suctioning an infant’s nares
Gloves
Wash hands prior to gloving. Suction
nare. Remove gloves, wash hands.
Irrigating a feeding tube
Gloves
Wash hands prior to gloving. Irrigate
feeding tube. Remove gloves, wash
hands.
Changing an infant’s wet diaper
PPE Used
IV.D.1.g
IV.D.1.h
IV.D.2.a
UNIT IV
Section D.2
Caring
Critical Elements for Caring
1.Establishes communication with the patient at the beginning
of the Implementation Phase by
a.
Introducing self
AND
b.Identifying the patient by verifying two of the following pieces
of patient information
1)
Patient name
2)
Date of birth
3)
Medical record number
c.
Explaining the purpose of the interaction
AND
OR
d.Using touch with a patient who is a child or noncommunicating
adult if culturally appropriate
2.Uses therapeutic communication techniques consistent with the
patient’s level of understanding to interact with the patient and
significant others by
a.
Encouraging the patient’s expression of needs
b.
Responding to the patient’s verbal expressions
c.
Responding to the patient’s nonverbal expressions
d.
Facilitating goal-directed interactions by
1)
Exploring the nursing actions to be taken
2)Asking questions to determine the patient’s response to
nursing care
3)
Asking questions to determine the patient’s comfort level
4)
Focusing communication toward patient-oriented interests
5)Eliciting the patient’s choices/desires in the organization
of care
IV.D.2.b
3.Uses verbal expressions that are not overly familiar, patronizing,
demeaning, abusive, or otherwise unacceptable
4.Uses physical expressions that are not overly familiar, patronizing,
5.Relates in a manner that respects the values, dignity, and culture
of others
Caring is a pattern of behaviors that pervades the nurse-patient interaction
as characterized by attentiveness to the experience of others, the
establishment of a trusting relationship with the patient and/or significant
other, and respect for the values, dignity and culture of others.
Caring is evaluated during all phases of every PCS. Application of the principles
of caring requires that you establish a helping relationship with the patient based
on trust and respect. Even though you will be with the patient for only 2½ hours,
it is expected that you will be sensitive to your patient as a unique human being,
recognizing and respecting the patient’s needs, values, dignity, and culture. You will
be required to establish and maintain therapeutic communication with your patient,
maintain confidentiality, and listen and respond to your patient’s verbal and nonverbal
communication during the PCS. You are to sign a confidentiality statement as part of
your application for the CPNE whereby you agree to protect patient confidentiality and
only share patient specific information with those persons who directly care for your
assigned patient.
1. Establishes communication with the patient at the beginning
of the Implementation Phase by
a.
Introducing self
AND
b.Identifying the patient by verifying two of the following pieces
of patient information
1)
Patient name
2)
Date of birth
3)
c.
Explaining the purpose of the interaction
AND
OR
d.Using touch with a patient who is a child or noncommunicating
adult if culturally appropriate
You will be expected to communicate professionally and courteously with
your patient throughout each PCS. Behavior that is attentive, enhances trust,
and is respectful generates an environment in which effective nursing care
can be implemented. When interacting with a patient, sit at the same level as
Overriding Areas of Care – Caring
IV.D.2.c
the patient, maintain eye contact, and allow time in silence for the patient to
respond to your comments, questions, suggestions, or instructions. Address
adult patients by the title of Mr., Mrs., Ms., etc., unless the patient directs
you otherwise. You are to identify your patient at the very beginning of the
Implementation Phase, prior to initiating any care for your patient.
Below are two examples of how you might greet your patient.
1.“Good morning, Mr. Duncan, I’m Mary Smith, a nursing student from
Excelsior College. I’ll be caring for you during the next 1½ hours. I will be
administering your 9:00 medications, assessing your lungs, monitoring your
IV, and helping you to be comfortable this morning. May I check your name
tag and identification number?”
2.In a child PCS, you might pick up and hold the child after introducing yourself
to the parent(s), being sure to apply principles of asepsis. When caring for
a noncommunicating adult, it is important to continue to explain actions
as you provide care. For example, you might say, “I am going to turn and
position you on your left side.” Since personal space and touch are culturally
determined, you should take culture into consideration when implementing
care. For example, if the patient’s family indicates discomfort with touch,
touch would be reserved for activities that are necessary for carrying out
the prescribed medical and nursing regimen. You may identify the child
yourself or request an identification from the parent. You are still required
to assess the child’s ID number against the assignment Kardex.
2.Uses therapeutic communication techniques consistent with the
patient’s level of understanding to interact with the patient and
significant others by
a.
Encouraging the patient’s expression of needs
b.
Responding to the patient’s verbal expressions
c.
Responding to the patient’s nonverbal expressions
d.
Facilitating goal-directed interactions by
1)
Explaining the nursing actions to be taken
2)Asking questions to determine the patient’s response
to nursing care
3)
Asking questions to determine the patient’s comfort level
4)
Focusing communication toward patient-oriented interests
5)Eliciting the patient’s choices/desires in the organization
of care
Therapeutic communication techniques are used to interact with the patient
during each PCS. You are expected to communicate in English. At times,
however, assigned patients may not speak English as their primary language.
Devices such as translation cards, which assist in communication, may be
used during the CPNE.
IV.D.2.d
You are expected to demonstrate your commitment to your patient’s needs
through application of the Critical Elements of Caring in communicating and
establishing a therapeutic relationship. To facilitate a therapeutic relationship
with the patient, you explain nursing actions to be taken and ask questions to
determine the patient’s response to nursing care. Your ability to communicate
therapeutically will be assessed by observing how you direct the focus of
communication toward patient-oriented interests and use language consistent
with the patient’s level of understanding. Your application of the principles of
caring will also be evaluated by observation of the way you respond to the
patient’s needs. For example, if a child is crying, you should take an action aimed
at calming the child such as enlisting the parent’s help as you care for the child.
Eliciting the patient’s choices and desires in the organization of care
communicates that you are there for the patient and care about the patient’s
preferences. One measure of quality of any hospitalization is the patient’s beliefs
and opinions about the treatment plan and patient care.
Case Study
An example of student behavior which would be in violation of Caring
principles is:
• A
patient asks to use the bathroom. You answer, “I will walk you
to the bathroom after I take your vital signs.”
In this example: Unless there is a clinical reason, measuring vital signs
first might indicate to the patient that his or her immediate needs
are not your first priority. Although you may be anxious in a testing
situation, it would be wise to remember that completing your tasks
without consideration of the patient’s needs may violate the Critical
Element for Caring.
3. Uses verbal expressions that are not overly familiar, patronizing,
4. Uses physical expressions that are not overly familiar, patronizing,
Remember that nonverbal communication and body language often speak louder
than words. Ninety percent of your communication is expressed through your
nonverbal behaviors. Feeling confident and being prepared for the performance
examination by knowing the Critical Elements will help you to establish a
supportive relationship with your patient and focus on your patient’s needs.
Overriding Areas of Care – Caring
IV.D.2.e
5. Relates in a manner that respects the values, dignity, and culture
of others
Communicate with your patient using verbal and nonverbal expressions that
show respect for the values, dignity, and culture of others. Calling a patient by
name shows respect for the individual. In contrast, calling a patient “Sweetie”
or “Hon” shows lack of respect, is demeaning, and is unprofessional. Sitting with
a patient at eye level sends a message that you are interested in what the patient
is saying. Standing at the door and glancing at your watch conveys a very
different attitude. Issues of unprofessional conduct in a patient situation will
be evaluated using Critical Elements in the Caring Overriding Area of Care
For the following situations, assume the role of the CE, and assess the students
caring behaviors. Provide your rationale for assessing the student’s behavior as
a pass or fail. If the behavior is determined to be unacceptable, what would you
do to correct the situation?
Behavior
1.
The student is assigned a 94 y/o
patient who is post right total hip
replacement (THR). The patient
answers every question with many
details. The student feels rushed to
get the Areas of Care completed.
The two remaining Areas of Care are
Peripheral Vascular Assessment and
Respiratory Assessment; there are
50 minutes remaining in the PCS.
The patient feels the need to tell the
student all the details of the surgery
and recovery to date. The student sits
down and listens attentively.
2.
The student is assigned a 4-monthold baby with bronchitis. At the
beginning of the Implementation
Phase, the student enters the room
and, after washing her hands, picks
up the baby and begins to assess
lung sounds. The parents are at the
bedside.
3.
The student is assigned a patient
with terminal cancer of the cervix.
The student enters the room, checks
her ID band, and tells her the care
that will be performed. The student
immediately begins to check the
Foley catheter.
Pass
Fail
Rationale/Corrective Action
IV.D.2.f
Caring
For the following situations, assume the role of the CE and assess the student’s caring
behaviors. Provide your rationale for assessing the student’s behavior as a pass or fail.
If the behavior is determined to be unacceptable, what would you do to correct the
situation?
1. The student is assigned a 94-year-old who is post right total hip replacement
(THR). The patient answers every question with many details. The student
feels rushed to get the Areas of Care completed. The two remaining areas of
care are Peripheral Vascular Assessment and Respiratory Assessment; there
are 50 minutes remaining in the PCS. The patient feels the need to tell the
student all of the details of the surgery and recovery. The student sits down
and listens attentively.
Pass. The time spent listening to the patient will assist in gaining the patient’s
cooperation for the remaining Areas of Care, and demonstrates the student’s caring
behaviors. The time remaining is sufficient to complete these two Areas of Care
and the Evaluation Phase of the PCS.
2. The student is assigned a 4 month old baby with bronchitis. At the beginning
of the Implementation Phase, the student enters the room and after washing
her hands, picks up the baby and begins to assess the lung sounds. The parents
are at the bedside.
Fail. Student should have introduced herself to the parents and explained what
she was going to do for the baby.
3. The student is assigned a patient with terminal cancer of the cervix. The
student enters the room, checks her ID band and tells her the care that will
be performed. The student immediately begins to check the Foley catheter.
Fail. First the student should have introduced herself and focused the interaction
on the patient’s concerns and interests. Next, the student should have washed her
hands before initiating any patient care.
IV.D.3.a
UNIT IV
Section D.3
Emotional Jeopardy
Emotional Jeopardy is any action or inaction on the part of the student
which threatens the emotional well-being of the patient or significant others.
Emotional Jeopardy is invoked at the discretion of the CE, validated with
the patient or significant other, and supported by data from the clinical
situation. The entire PCS will be terminated and failed any time the
emotional well-being of the patient or significant other is threatened.
Establish a patient care relationship that promotes the emotional well-being of the
patient and significant others. Behavior the CE determines to be a threat to the
patient’s or significant other’s emotional well-being would constitute a violation of
Emotional Jeopardy and would be grounds for failure of the PCS. During a testing
situation, it may be easy to become so focused on the Critical Elements of the
examination that you lose sight of the patient’s emotional needs. You must be aware
of and sensitive to the patient’s response to the care provided at all times. Caring and
Emotional jeopardy are interrelated Areas of Care.
Examples of actions that promote emotional well-being:
•Listening attentively as the patient explains why she is worried about returning
home to care for herself after her recent surgery.
•Offering a patient a tissue and sitting down next to him as he discusses the
recent loss of his wife and weeps.
•Referring the patient’s concerns to the appropriate staff member.
•Using therapeutic communication techniques when speaking with the patient
and significant others.
•Incorporating culturally sensitive care in each PCS.
Examples of actions that violate emotional well-being:
•Exposing your patient unnecessarily while changing an abdominal dressing.
•Criticizing care given by others to the patient by saying something such as
“You look like you haven’t received any care all night.”
•Harshly saying to the patient, “I just explained everything about your
medications; weren’t you listening?”
IV.D.3.b
•Focusing on what needs to be done to complete the CPNE rather than
focusing on the patient’s verbal and non-verbal behavior.
•Removing items that the patient has indicated help him to cope with his illness
while preparing a work area and not replacing them when your care
is complete.
1.The student’s assignment includes Patient Teaching co-assigned with
Medications. After the student enters the room and washes his hands, he states,
“Mrs. Jones, I need to teach you about your medication. Obviously you do not
understand your medication, Digoxin. It is very important to be accurate when
you check your pulse. You also need to report any side effects.” Mrs. Jones starts
to cry and states, “This is too much information I want my regular nurse. I don’t
want you to take care of me.”
a.
What Area of Care or Critical Elements is the student violating?
_________________________________________________________________________
_________________________________________________________________________
b.
How should the student have approached the patient?
_________________________________________________________________________
_________________________________________________________________________
2. Student assignment: 7 year-old child admitted in sickle cell crisis. The Areas
of Care are Vital Signs, Oxygen Management, Respiratory Management, Fluid
Management, and Pain Management. The patient is curled in a fetal position,
legs drawn up, covers over head, light and TV off, quietly crying. Father sitting
in chair by bedside. At the beginning of the Implementation Phase the student
walks in with BP cuff; takes the blood pressure, then leaves the room.
a.
_________________________________________________________________________
_________________________________________________________________________
b.
_________________________________________________________________________
_________________________________________________________________________
Overriding Areas of Care –Emotional Jeopardy
IV.D.3.c
Emotional Jeopardy
1. The student’s assignment includes Patient Teaching coassigned with
Medications. After the student enters the room and washes his hands, he states,
“Mrs. Jones, I need to teach you about your medication. Obviously you do not
understand your medication Digoxin. It is very important to be accurate when
you check your pulse. You also need to report any side effects.” Mrs. Jones starts
to cry and states, “This is too much information. I want my regular nurse. I don’t
want you to take care of me.”
a.
This would be a failure under Emotional Jeopardy because the student has
upset the patient to the point of being asked to leave.
b.
The student was assigned Patient Teaching. Therefore, after introducing
himself, it would have been necessary to first assess the patient’s learning need
and the patient’s readiness to learn.
2.Student assignment: 7-year-old admitted in sickle cell crisis. The Areas of
Care are Vital Signs, Oxygen Management, Respiratory Management, Fluid
Management, and Pain Management. The patient is curled in fetal position,
legs drawn up, covers over head, light and TV off, quietly crying. Father sitting
in chair by bedside. At the beginning of the Implementation phase the student
walks in with BP cuff; takes the blood pressure, then leaves the room.
a.
The student is violating the Critical Elements for the Area of Care: Caring,
the Critical Elements of establishing communication with the patient at the
beginning of the Implementation Phase and explaining nursing actions to
be taken.
b.
How should the student have approached the patient and family member?
The student should have quietly introduced self to the patient and the father,
asked the child to describe the pain level, and asked what she could do to
make the patient more comfortable. Should have deferred vital signs until later
in the PCS.
IV.D.3.d
IV.D.4.a
UNIT IV
Section D.4
Mobility
Critical Elements for Mobility
1. Assesses the patient for
a.
Level of mobility
b.
Use of assistive devices
c.
Presence of balance abnormalities
2. Moves or positions the patient by
a.
Supporting the weak or injured parts of the body
b.
Supporting the patient’s head, shoulders, and pelvis
c.
Turning, lifting, or moving the patient to a different position
d.Using body parts or external devices to keep the patient in
the desired position
e.Using positioning and/or devices to reduce pressure on
vulnerable skin surfaces
f.
Using measures to prevent shearing of skin
3. Assists with transfer or ambulation by
a.
Stabilizing equipment
b.
Using measures to maintain the patient’s balance
4. Records
a.
Data related to
1)
Level of mobility
2)
3)
b.Positioning, transfer, or ambulation activities completed
during the PCS
c.Patient’s response to the positioning, transfer, and/or
ambulation activities
IV.D.4.b
Mobility is the partial or complete assistance with positioning, transfer,
and/or ambulation activities. The patient may be in or out of bed and may
or may not require supportive devices or a cast, but requires assistance
or supervision.
Mobility is in effect and evaluated during all phases of every PCS. The Critical
Elements of Mobility apply to all patients. Application of the principles of mobility
requires you to think about the patient’s current ability to move and the use of
assistive devices. After you complete your assessment of balance and safety needs,
you will supervise an ambulatory patient, help the patient to move, or reposition
the patient.
The CE will designate mobility activities on the PCS Assignment Kardex that the
patient’s condition or treatment plan requires. For example, the CE may write:
“Assist patient with transfer and ambulate in hall times one.” You have
the entire PCS to complete the Critical Elements for Mobility.
You are not required to perform any Critical Element in Mobility that does not
pertain to your patient (based on your assignment and your patient’s condition).
Case Study
You are assigned to ambulate a 5-year-old child admitted 3 days ago
with sickle cell crisis, who is receiving pain medications, IV fluids and
oxygen. The patient tells you she is still in pain, pointing to the face that
corresponds to a 4 on a faces pain scale, has a headache, wants the lights
turned off, misses her mommy, and just doesn’t want to move or watch
television. You verbalize to the CE “I will not get this patient out of bed at
this time due to her pain level and her overall disposition. I will report to
the assigned nurse her current pain level and ask the nurse to medicate the
patient. I will also determine the last time she had any family visitations,
and see if the assigned nurse knows when the family is due to visit again.”
1. Assesses the patient for
a.
Level of mobility
Assessment of mobility includes observation of the patient’s ability to
move about freely. For each PCS, assess and document your patient’s
level of mobility, including any condition where mobility is impaired or
therapeutically restricted.
b.
Assistive Devices: Equipment or person used by the patient to aid
ambulation or movement. Some examples of equipment include canes,
walkers, crutches, wheelchairs, transfer boards, trapeze bars, and
mechanical lifts.
Overriding Areas of Care –Mobility
c.
IV.D.4.c
The patient’s balance, posture, and self-control of movements along with
ability to ambulate and complete activities of daily living should guide you
in developing your plan of care. Clinical data obtained from the patient has
direct implications for safety and supportive care.
2. Moves or positions the patient by
a.
Supporting the weak or injured parts of the body
b.
Supporting the patient’s head, shoulders, and pelvis
c.
Turning, lifting, or moving the patient to a different position
d.Using body parts or external devices to keep the patient in the
desired position
e.Using positioning and/or devices to reduce pressure on vulnerable
skin surfaces
f.
Using measures to prevent shearing of skin
You are to move or reposition your patient at least once during every PCS. If the
patient is on bed rest, the CE will designate repositioning on the PCS Assignment
Kardex. When repositioning is indicated on the PCS Assignment Kardex, you
will be expected to move your patient to a different position. Turning the patient
from lying supine during a back rub and then returning the patient to the supine
position does not constitute repositioning.
The CE will designate any contradictions for mobility on the PCS Assignment
Kardex. You are to reposition a patient with traction. Supportive devices such as
pillows, splints, trochanter rolls, traction, and siderails may be used to support
and position the patient. Heel protectors may be used to reduce pressure to the
patient’s heel area.
1.
What is the meaning of the phrase “to position in proper body alignment”?
_________________________________________________________________________
_________________________________________________________________________
2.What patient conditions require limitations or modifications of positioning
mobility?
_________________________________________________________________________
_________________________________________________________________________
IV.D.4.d
3. Assists with transfer or ambulation by
a.
Stabilizing equipment
b.
Using measures to maintain the patient’s balance
When designated, you will be required to ambulate your patient. The degree of
activity allowed depends on your patient’s condition. Safe ambulation requires
that you are familiar with the basic principles of body mechanics and safe
transfer as well as with the use of assistive devices for transfer and ambulation.
For each PCS, when transferring or ambulating your patient you will need to
stabilize equipment and assist your patient in maintaining balance. Safe transfer
and ambulation requires you to think about how you will position yourself in
relation to the patient and when you should request the assistance of others.
In addition, think about what factors might influence your patient’s ability to
tolerate activity. It is acceptable for you to request the assistance of the assigned
staff nurse or the CE to help you move a patient. Provide direction to anyone you
ask to assist you with moving a patient.
3.Describe the procedure you would use to transfer an elderly female patient
with left sided hemiplegia to a wheelchair.
_________________________________________________________________________
_________________________________________________________________________
4.
How would you assist a patient with the use of a walker?
_________________________________________________________________________
_________________________________________________________________________
5.
How would you move a 7-year-old patient in leg traction up in bed?
_________________________________________________________________________
_________________________________________________________________________
6.
How would you assist an adult using crutches with ambulation?
_________________________________________________________________________
_________________________________________________________________________
7.How would you transfer a 2-year-old child in a hip spica cast from bed
to wagon?
_________________________________________________________________________
_________________________________________________________________________
IV.D.4.e
4. Records
a.
Data related to
1)
Level of mobility
2)
3)
b.Positioning, transfer, or ambulation activities completed
during the PCS
c.Patient’s response to the positioning, transfer, and/or
ambulation activities
Document your findings regarding the assessment of your patient’s mobility
status, positioning, transfer or ambulation activities completed and the patient’s
response to those activities implemented. Documentation is completed on the
Recording Form page of the PCS Response Form under Mobility.
An example of acceptable documentation:
“Sitting in chair slumped to left side. Hemiplegia of left arm and leg is present.
Sling supporting left arm and hand in place. Repositioned in chair, in proper
alignment, supported with pillows. Sling removed. Skin of arm and hand warm
and intact. States feeling more comfortable since being repositioned.”
8.What nursing diagnostic statement would you use as part of your care plan
for a 67-year-old patient who is s/p right total hip replacement (THR)?
_________________________________________________________________________
_________________________________________________________________________
9.Based on your readings about post-op THR patients, what would
be possible contributing factors that would lead you to the above
diagnostic label?
_________________________________________________________________________
_________________________________________________________________________
10.What indicators would you look for to help you decide whether the patient
is experiencing an actual problem or is at risk for a problem?
_________________________________________________________________________
_________________________________________________________________________
IV.D.4.f
11.Write one measurable expected outcome for the diagnostic label you
selected in question 8.
_________________________________________________________________________
_________________________________________________________________________
12. Write two interventions you plan to implement during the PCS?
_________________________________________________________________________
_________________________________________________________________________
13.What information would you need to collect during the Implementation
Phase to adequately evaluate the patient’s progress toward achievement
of the outcome and effectiveness of the nursing interventions?
_________________________________________________________________________
_________________________________________________________________________
14.What activities might be restricted for this patient? What assistive devices
might be used and why?
_________________________________________________________________________
_________________________________________________________________________
15.Write a narrative note for this patient based on the recording Critical
Elements for Mobility.
_________________________________________________________________________
_________________________________________________________________________
Mobility
1. What is the meaning of the phrase “to position in proper body alignment”?
Body should be positioned so that the joints are in a straight line to promote
patient comfort and prevent joint injury.
2. What patient conditions require limitations or modifications of positioning
and mobility?
A few examples might include patients who have fractures, are comatose, paralyzed,
have pressure ulcers or have had a joint replacement.
IV.D.4.g
3. Describe the procedure you would use to transfer an elderly female patient with
left hemiplegia to a wheelchair.
Place a wheelchair on unaffected side of the patient’s body. Support the patient by
standing directly in front of the patient, with your arms around the patient’s waist.
Have patient stand and pivot to the wheelchair.
4. How would you assist a patient with the use of a walker?
Instruct patient to raise the walker off the floor and move the walker a short distance
ahead then step into the walker.
5. How would you move a 7-year-old patient with leg traction up in bed?
Keep the patient in alignment. Have the patient use the overhead trapeze to lift the
body while you support the affected leg and guide the traction weights. Have the
patient use the unaffected leg to push up in bed.
6. How would you assist an adult to ambulate with crutches?
Teach patient to advance both crutches ahead, then swing both legs through while
supporting body weight on hand bars of the crutches. It is important not to support
body weight on axillae.
7. How would you transfer a 2-year-old child in a hip spica cast from bed to wagon?
Depending on the size of the child this may be a 1, 2 or more person lift. Position
wagon next to bed, apply brake or have staff person brace wagon to prevent rolling
if wagon does not have a brake. Slide child to edge of bed. Lift child and place in
wagon, maintaining child in correct body alignment.
8. What nursing diagnostic statement would you use as part of your care plan for
a 67-year-old patient status post total hip (right) replacement (THR)?
Impaired Physical Mobility R/T muscle weakness as evidenced by (AEB) patient
requiring assistance of 2 people to ambulate.
9. Based on your readings about post-op THR patients, what would be possible
contributing factors that would lead you to this diagnostic label?
For Total Hip replacement the necessary surgical manipulation of tissues, muscles
and the hip joint creates muscle weakness/injury and pain.
10. What indicators would you look for to help you decide whether the patient is
experiencing an actual problem or is at risk for a problem?
Weakness, facial grimacing, verbalization of pain by the patient, verbalization of
weakness by the patient and needing assistance to ambulate.
IV.D.4.h
11. Write one measurable expected outcome for the diagnostic label you selected
in question 8.
Patient will ambulate to the door of the room.
12. Write two interventions you plan to implement during the PCS.
Provide rest period before ambulation. Assist patient to standing position
maintaining proper alignment of hip joint.
13. What information would you need to collect during the implementation phase to
adequately evaluate the patient’s progress toward achievement of the outcome
and effectiveness of the nursing interventions?
Patient’s response to transfer and ambulation (endurance, strength). Patient used
proper transfer techniques standing effectively with hip in proper position. Patient
had ten minutes of rest before transfer then patient said he was ready to ambulate.
Ask yourself: was he able to ambulate to the door? If not, why not?
14. What activities might be restricted for this patient? What assistive devices might
be used and why?
Consider what has happened to this patient’s hip joint. Is there any danger of
dislocation of the artificial joint? You will need to restrict any flexion of the affected
hip. Use an abductor pillow to prevent adduction of the affected hip joint.
15. Write a narrative note for this patient based on the recording Critical Elements
for Mobility.
Patient ambulated to door with assistance of one using walker. Gait slow, but steady.
Tolerated ambulation without complaints of pain or dyspnea. Positioned in bed with
abductor pillow in place.
IV.D.5.a
UNIT IV
Section D.5
Physical Jeopardy
Physical jeopardy is any action or inaction on the part of the student which
threatens the patient’s physical well-being.
Physical Jeopardy is evaluated according to the definition provided above
and supported by the patient’s clinical condition. Any time the physical
safety of the assigned patient is threatened through omission (such as
not reporting deterioration in the patient’s clinical condition) or through
imminent incorrect action, the entire PCS will be terminated and a failure
will result. It is the responsibility of the CE to ensure that the patient is
protected from unsafe or threatening situations. When a CE is concerned
about a student’s action or inaction, the CE will prevent that student from
proceeding and will correct the situation and, if necessary, will call the CA
for consultation. The entire PCS will be terminated and failed any time the
physical well-being of the patient is threatened.
You are accountable for the patient’s safety throughout each PCS.
Examples of actions that would promote patient safety include the following:
• S
ecuring a 15-month-old child in a high chair using the tray and a lap belt
while working in the room
• A
pplying the brake to the wheelchair prior to assisting the patient with
standing and pivoting back to bed.
Actions that violate physical jeopardy include the following:
• T
ransferring a patient from bed to chair by pivoting without providing
footwear for the patient.
• F
ailing to follow the assignment as designated on the PCS Assignment Kardex.
For example, respiratory management with deep breathing and incentive
spirometry is assigned, and “Do not cough the patient” is written on the
Kardex. Proceeding to instruct the patient to deep breathe and cough may
place the patient in physical jeopardy.
• L
eaving an elderly patient alone in the bathroom after the patient verbalizes
that he/she feels weak, dizzy and lightheaded.
• L
eaving the patient’s bed in high position while you go to the clean
utility room.
IV.D.5.b
• Leaving a confused patient without their call light.
• W
riting an unsafe intervention on the Planning Phase Care Plan during
the Implementation Phase.
The PCS Assignment Kardex contains a section where all safety needs for the patient
are designated. It is also helpful to look in the section beginning with the words “For
Information Only” since this is where the CE will include other information about the
patient’s course of treatment as well as Areas of Care that you are not assigned but
would need to be aware of. One example would be if the patient were on Oxygen
Therapy but you were not assigned Oxygen Management as a Selected Area of Care.
The CE would write the patient’s oxygen orders under For Information Only.
Overriding Areas of Care –Physical Jeopardy
IV.D.5.c
For the following examples, rate the student’s behavior as pass or fail for the Area of
Care Physical Jeopardy.
Behavior
1.
Student Assignment: 86 y/o patient s/p
appendectomy. The Areas of Care assigned
are Vital Signs, Fluid Management, Respiratory
Assessment, Comfort Management, and Oxygen
Management. After initial handwashing, the
student obtains patient’s temperature (101º F).
Baseline temperature is afebrile. The student
proceeds to check IV site and fluids, then does
respiratory assessment. Student then offers
comfort measures.
2.
cholecystectomy. The Areas of Care are
Vital Signs, Fluid Management, Respiratory
Assessment, Comfort Management, and
Oxygen Management. After initial handwashing,
the student assesses the IV site and verifies
drops/min of gravity flow IV and obtains a
temperature of 101ºF. Baseline temperature is
afebrile. Invokes CDM to complete respiratory
assessment prior to reporting vital signs. After
completing respiratory assessment, reports
temperature to primary nurse.
3.
Student Assignment: 47 y/o male patient with
deep vein thrombosis (DVT) on IV heparin
drip. The Areas of Care are Vital Signs, Fluid
Management, Medications, Patient Teaching
assigned with Medications, and Peripheral
Vascular Assessment. The student enters room
for the PCS. After initial handwashing the
student takes vital signs and assesses IV site/rate
on infusion control device. The patient is restless
and asks the student to get personal belongings
in the closet. Student hands overnight bag to
patient. Patient opens bag and puts belongings
on bedside stand: Toothpaste, toothbrush,
shaving cream, straight razor, aftershave,
chapstick, and comb. The student leaves the
room to prepare medications.
4.
Student Assignment: 8-month-old infant with
cleft lip repair. The Areas of Care are Vital Signs,
Fluid Management, Enteral Feeding, Respiratory
Assessment, Personal Cleanliness. The student
crosses the room to document and leaves crib
side rail down.
Pass
Fail
Rationale/Corrective
Action
IV.D.5.d
Physical Jeopardy
For the following examples, rate the student’s behavior as pass or fail for the Area of
Care Physical Jeopardy.
Behavior
Pass
Fail
Rationale/Corrective
Action
1.
appendectomy. The Areas of Care assigned
are Vital Signs, Fluid Management, Respiratory
Assessment, Comfort Management, and Oxygen
Management. After initial handwashing, the
student obtains patient’s temperature (101º F).
Baseline temperature is afebrile. The student
proceeds to check IV site and fluids, then does
respiratory assessment. Student then offers
comfort measures.
2.
cholecystectomy. The Areas of Care are
Vital Signs, Fluid Management, Respiratory
Assessment, Comfort Management, and
Oxygen Management. After initial handwashing,
the student assesses the IV site and verifies
drops/min of gravity flow IV and obtains a
temperature of 101ºF. Baseline temperature is
afebrile. Invokes CDM to complete respiratory
assessment prior to reporting vital signs. After
completing respiratory assessment, reports
temperature to primary nurse.
3.
Student Assignment: 47 y/o male patient with
deep vein thrombosis (DVT) on IV heparin
drip. The Areas of Care are Vital Signs, Fluid
Management, Medications, Patient Teaching
assigned with Medications, and Peripheral
Vascular Assessment. The student enters room
for the PCS. After initial handwashing the
student takes vital signs and assesses IV site/rate
on infusion control device. The patient is restless
and asks the student to get personal belongings
in the closet. Student hands overnight bag to
patient. Patient opens bag and puts belongings
on bedside stand: Toothpaste, toothbrush,
shaving cream, straight razor, aftershave,
chapstick, and comb. The student leaves the
room to prepare medications.
X
Patient receiving
Heparin should be on
bleeding precautions
therefore should not
be using straight
razor.
4.
Student Assignment: 8-month-old infant with
cleft lip repair. The Areas of Care are Vital Signs,
Fluid Management, Enteral Feeding, Respiratory
Assessment, Personal Cleanliness. The student
crosses the room to document and leaves crib
side rail down.
X
Leaving crib rail down
on any infant or child
is a failure because
it places the child in
Physical Jeopardy.
X
X
Student should
have reported this
significant elevation in
temperature for this
elderly patient who
may have an infection.
Student obtained
additional data before
reporting.
IV.E
UNIT IV
Section E
Fluid Management
Vital Signs
Required Areas of Care are tested in every Patient Care Situation for every student.
IV.E.1.a
UNIT IV
Section E.1
Critical Elements for Fluid Management
1. Assesses the hydration status of the patient by one of the
following methods:
a.
Checking skin turgor
b.
Inspecting the mucous membranes
c.
OR
OR
Palpating the anterior fontanel of a child less than 1 year of age
2. For enteral fluids:
a.
Determines the kinds of fluid to be ingested
b.
Administers or restricts fluids as designated
3. For parenteral fluids:
a.
Within 20 minutes after beginning the Implementation Phase:
1)
Verifies the accuracy of the flow rate by either
a)
Counting the drops per minute currently flowing
b)Documenting that the flow rate of the infusion control
device is set at the exact number required to deliver
the prescribed volume by writing the setting on the PCS
Recording Form
2)Assesses the insertion site of peripheral, central, or implanted
venous access devices for dislocation, infiltration, or other
complications by using one of the following methods:
a)Feeling the surrounding skin for changes in temperature
b)
OR
Palpating the surrounding tissue for edema
3) Regulates the flow rate when required by either
a)Adjusting flow to within ± 5 drops per minute (regular
or microdrops) of the calculated number of drops per
minute
OR
OR
IV.E.1.b
b)Adjusting the flow rate of the infusion control device
to the exact number required to deliver the prescribed
volume
4) Records the prescribed fluid infusing on the PCS
Recording Form
Throughout the Implementation Phase:
b.
1)
2)Administers the designated amount of fluid per hour within
the following ranges ( as long as this amount of error does
not place the patient in physical jeopardy):
Administers the prescribed fluids
a)
± 25 ml per hour for a patient over 2 years
b)
OR
± 10 ml per hour for a patient under 2 years
3)Recalculates the flow rate or adjust the ICD setting if the
physician’s order changes
4)When the next prescribed primary IV fluid is required:
a)Selects the designated fluid
b)Calculates the amount of fluid to infuse per specified
period of time
c)Identifies the patient immediately before administering
the IV solution by verifying two of the following pieces
of information:
(1) patient name
(2) date of birth
(3) medical record number
d)Assesses the insertion site of peripheral, central,
or implanted venous access devices for dislocation,
infiltration, or other complications by using one of
the following methods:
(1)Feeling the surrounding skin for changes
in temperature
OR
(2) Palpating the surrounding tissue for edema
Clears IV tubing of air before initiating the flow
e)
Required Areas of Care –Fluid Management
f)
Regulates the flow rate by either
(1)Adjusting the flow to within ± 5 drops per minute
(regular or microdrops) of the calculated number
of drops per minute
IV.E.1.c
OR
(2)Adjusting the flow rate of the infusion control
device to the exact number required to deliver
the prescribed volume
g)Records on the PCS Recording Form the new fluid
being administered
5)When maintenance of an intermittent venous access device
is required:
a)Assesses the insertion site of peripheral, central,
or implanted venous access device for dislocation,
infiltration, or other complications by
in temperature
OR
(2)Palpating the surrounding tissue for edema
b)
Aspirates for blood return, unless contraindicated
c)Flushes the intermittent access device with the
designated flush solution
d)
When a peripheral IV is to be discontinued:
6)
Records the flush solution on the PCS Recording Form
a)
Assesses condition of IV site
b)
Removes the cannula
c)
Applies pressure to the venipuncture site
d)
Applies a protective covering
4. When enteral and/or parenteral intake is assigned:
a.
Measures the amount of fluid ingested/infused
b.
Records fluid intake within ± 10% of the actual intake
c.Records the kind(s) of fluids ingested/infused
d.Records hourly intake on PCS Recording Form within ± 10 minutes
of the designated time when hourly intake is assigned.
IV.E.1.d
5. When output is assigned:
a.
Collects output
b.
Measures output during the entire PCS
c.Records amount of output within ± 10% of the actual output for
the PCS on the PCS Recording Form (output from urinary retention
catheters or other drainage apparatus is not measured during the
PCS unless otherwise designated)
d.Records amount of hourly output on the PCS Recording Form
within ± 10 minutes of the designated time when hourly output
is assigned.
6. Records data related to
a.
Hydration status
b.Condition of insertion site for peripheral, central, or implanted
venous access devices
Fluid Management involves the assessment of hydration status, the
administration of fluid enterally and parenterally (central or peripheral),
and, when designated, the measurement of intake and output (I & O).
Fluid management will be assigned for every PCS during the CPNE. Assessments
include patient’s hydration status, monitor and measure fluid intake and output (I&O)
when designated, administer or restrict fluids as ordered, and monitor an intravenous
(IV) infusion. For IV maintenance, you are to assess the patency of an IV site, regulate
the flow of a gravity drip IV, monitor an infusion control device (ICD), change IV
bags/bottles or prime IV tubing, and determine the amount of parenteral fluids when
completely infused. You may be assigned to flush an intermittent venous access
device or discontinue an existing IV infusion.
For the purpose of this examination, you will monitor only one IV during a PCS.
If the patient has more than one IV, the IV that you will be expected to monitor will
be designated on the PCS Assignment Kardex. The assignment will also indicate who
is responsible for any other IVs. IV fluids can be administered via peripheral or central
venous access.
You might monitor a variety of IV fluids through the following:
Central Venous Access Devices
Peripheral Sites
Total Parenteral Nutrition (TPN)
Amino acids
Lipids
Hypotonic or isotonic solutions
IVs containing medications
(potassium chloride, heparin,
vitamins, etc.)
Hypotonic or isotonic solutions
IVs containing medications
(potassium chloride, heparin,
vitamins, etc.)
IV.E.1.e
You will not be expected to administer blood or blood products, insert IV catheters,
perform any venipunctures, or flush a central line during the CPNE.
1. Assesses the hydration status of the patient by one of the
following methods:
a.
Checking skin turgor
b.
Inspecting the mucous membranes
c.
OR
OR
Palpating the anterior fontanel in a child less than 1 year of age
Assess the patient’s hydration status by either checking skin turgor or inspecting
mucous membranes for a child over one year old or an adult patient. Palpate the
anterior fontanel of a child under one year of age. Assessment of the oral cavity
may place you at risk for body fluid pathogen transmission; therefore, Standard
Precautions must be maintained. You should be able to differentiate between
normal and abnormal findings, identify signs and symptoms of fluid deficit or
excess, and report any change that indicates an improvement or deterioration in
the patient’s clinical condition to the assigned staff nurse.
Since the assessment of hydration status may be done unobtrusively, be obvious
in your actions when performing this assessment and verbalize your findings
to alert the CE that you are completing the Critical Elements. A great way to do
this is to talk with your patient, explaining nursing actions to be taken as you
perform the Critical Elements for the examination. Document your findings on
the PCS Recording Form page of your Student PCS Response Form under the
area titled Hydration Status.
During the Planning Phase, reviewing pertinent laboratory data such as BUN,
Hct, Hgb, and serum Na levels may be helpful in determining whether your
patient has a fluid excess or deficit. Use the information obtained to support the
nursing diagnosis of fluid volume excess or deficit when writing and formulating
you nursing care plan.
IV.E.1.f
Determine the significance of the following assessment findings and the nursing
actions you would take in response to such findings.
Assessment Finding
1.
A bulging fontanel for an infant
2.
A depressed fontanel for an infant
3.
Skin tenting and moist oral mucus
membranes for an elderly patient
4.
Dry, flaky skin for a postoperative patient
who is taking clear liquids
5.
No tenting, capillary refill <3 seconds.
Significance
Nursing Action Required
2. For enteral fluids:
a.
Determines the kind(s) of fluid to be ingested
b.
Administers or restricts fluids as designated
The CE will write your patient’s diet and fluid orders on the PCS Assignment
Kardex. You are responsible for following those orders (e.g., NPO, encourage,
restrict). If the patient is on a fluid restriction, the CE will designate how much
fluid the patient can receive within a particular time frame.
Case Study
As you read the PCS Assignment Kardex, you see that the CE has
designated “Encourage fluids.” During the Implementation Phase, your
patient complains of nausea and starts to vomit. You decide to modify
the nursing intervention. Before modifying the intervention, you invoke
CDM by telling the CE, “I am not encouraging fluids because the patient
is vomiting. I will report this to the assigned staff nurse.”
3. For parenteral fluids:
a.
1)
Verifies the accuracy of the flow rate by either:
a)
OR
b)Documenting that the flow rate of the infusion control
device is set at the exact number required to deliver
the prescribed volume by writing the setting on the PCS
Recording Form
IV.E.1.g
Within 20 minutes of beginning the Implementation Phase verify the flow rate
of the designated intravenous fluid; remember to accurately record on the PCS
Response Form the prescribed fluid infusing. By documenting your assessment
findings as you complete the Critical Elements, you decrease the risk of
forgetting to complete your documentation.
The type of IV the patient has infusing, the rate, and whether the IV is infusing
by gravity flow or ICD will be indicated on the PCS Assignment Kardex. If the
IV is infusing by gravity, the drop factor of the tubing will also be indicated.
Remember that you should have calculated and documented the drops per
minute for a gravity flow IV during the Planning Phase.
When an infusion control device (ICD) is used, your responsibility is to determine that the correct solution is infusing and the ICD is set correctly and for
documenting this setting on the PCS Recording Form page of the Student PCS
Response Form. Be obvious when obtaining this information.
You are not responsible for troubleshooting equipment problems. You will,
however, be responsible for monitoring that the fluid is infusing at the prescribed
rate throughout the PCS and that it does not run out. If the ICD alarm sounds the
CE will expect you to assess the IV site and the tubing to identify and eliminate
any obvious problems such as kinking of the tubing or site infiltration. Ask the
CE or assigned staff nurse to assist with turning off the alarm once the problem
has been corrected. If you ignore the alarm and the CE feels the patency of
the IV will be compromised, your PCS will be stopped and the failure will be
cited as related to Physical Jeopardy. The CE will orient you to the specific ICD
equipment, but it is expected that you will have some experience with ICDs and
will be familiar with the principles of their use prior to taking the CPNE.
2)Assesses insertion site of peripheral, central, or implanted
venous access devices for dislocation, infiltration, or other
complications by using one of the following methods:
a)
Feeling the surrounding skin for changes in temperature
b)
OR
Assessing the IV site comprises the second group in the series of timed Critical
Elements, which are to be completed within the first 20 minutes of beginning
the Implementation Phase. For the purpose of this examination only the two
methods identified in the Critical Elements are acceptable. Be alert to key words
in the Critical Elements.
IV.E.1.h
Standard Precautions are maintained when assessing an IV insertion site. Gloves
are worn when palpating any IV site including one covered with a transparent
dressing. Transparent dressings may be either semipermeable or nonpermeable.
Dressings that are permeable or semipermeable do not provide a barrier to
prevent risk of exposure to blood or body fluids.
Patients with either peripheral or central venous access devices may be
assigned for the PCS. Centrally located venous access devices may be external
or implanted. Hospital protocols require checking the insertion site of central
venous access devices differently than checking peripheral lines. The removal
of sterile dressings to assess for complications of central lines is usually
contraindicated. Two complications of administering IV fluids via central lines
are dislocation and insertion site infection. Therefore, if the insertion site can be
visualized (i.e., covered by a transparent dressing), perform Critical Element 2a)
or 2b) to assess for potential infection and/or dislocation. When the insertion
site is covered with a large gauze dressing that would make visualization and
palpation of the IV site difficult (e.g., central line or for a pediatric patient), you
should verbalize to the CE that you cannot determine the condition of the site.
You are not required to check an intermittent venous access device if there is no
fluid infusing and maintenance of the intermittent venous access device is not
assigned.
The CE will assess the site and IV to ensure neutrality of the situation prior to the
start of the PCS. Should you enter the Implementation Phase and find an IV site
that has infiltrated, notify the assigned staff nurse.
3)
Regulates the flow rate when required by either
a)Adjusting flow to within ± 5 drops per minute
of drops per minute
OR
b)Adjusting the flow rate of the infusion control
4)Records the prescribed fluid infusing on the
PCS Recording Form
The Critical Element of regulating the flow when assigned is the third timed
element. The Critical Elements specify that gravity flow IVs are to be regulated
to within ± 5 drops per minute of the calculated number of drops per minute.
Regulation of an ICD, however, must be exact. The pump is designated to
deliver an exact amount of fluid over a period of time. There is no margin of
error acceptable for regulating the volume on an ICD. Document the current IV
infusing on the PCS Recording Form page of the Student PCS Recording Form
within the first 20 minutes of the beginning of the Implementation Phase.
IV.E.1.i
6.You enter an adult patient’s room and greet your patient. After washing
your hands and putting on gloves, you assess the IV site. You then verify
the drip rate of a gravity flow IV or the ICD setting. What if the ICD was set
at the wrong rate or if the expected drops (gtts) per minute was 17 and you
found the rate to be 24 gtts per minute? What should you do?
_________________________________________________________________________
_________________________________________________________________________
7.If the IV were running at 6 gtts/minute over the correct drip rate, what is
the potential consequence of administering excess fluid to the patient?
_________________________________________________________________________
_________________________________________________________________________
8.If the IV was running at 6 gtts/minute less than the expected drip rate,
what is the possible consequence over a 24-hour period?
_________________________________________________________________________
_________________________________________________________________________
9.What could the consequences be for a six-year-old if the IV drop rate
was inaccurate?
_________________________________________________________________________
_________________________________________________________________________
10.Why is there a margin of error in the CPNE for regulating fluids by
gravity drip?
_________________________________________________________________________
_________________________________________________________________________
b.
Throughout the Implementation Phase:
1)
2)Administers the designated amount of fluid per hour within
the following ranges (as long as this amount of error does not
place the patient in physical jeopardy)
Administers the prescribed fluids
a.
± 25 ml per hour for a patient over 2 years
b.
OR
± 10 ml per hour for a patient under 2 years
3)Recalculates the flow rate or adjusts the ICD setting if the
physician’s order changes
IV.E.1.j
You are responsible for monitoring the IV throughout the PCS to make sure the
correct fluid infuses at the correct rate. If the volume is greater than ± 25 ml per
hour for a patient over 2 years of age or ± 10 ml per hour for a patient under 2
years of age, the patient is put at risk of fluid volume deficit or overload. This is
not acceptable in patient care, nor is it acceptable for the CPNE. The margin of
error built into the Critical Elements for a testing situation takes into account
the fact that sometimes IVs are positional. Monitor the volume in the IV bag to
determine that the correct volume is infusing. Establish the amount of IV fluid
left in the IV bag with the CE as you begin the Implementation Phase.
Check to be sure that the IV tubing is not kinked or otherwise obstructed.
Kinking of the tubing or a change in flow rate may occur if the patient changes
position. If the IV flow rate is changed or if you determine that the IV should be
infusing at 34 gtts/min and it is flowing at 45 gtts/min, it will be necessary to
adjust the flow rate. You are to reset the flow rate on the infusion control device
if the physician’s order changes.
4)
When the next prescribed primary IV fluid is required:
a)
Selects the designated fluid
b)Calculates the amount of fluid to infuse per specified
period of time
c)Identifies the patient immediately before administering
the IV solution by verifying two of the following pieces
of information:
(1) patient name
(2) date of birth
(3) medical record number
d)Assesses the insertion site of peripheral, central,
or implanted venous access devices for dislocation,
infiltration, or other complications by using one of
the following methods:
in temperature
OR
(2) Palpating the surrounding tissues for edema
e)
Clears IV tubing of air before initiating the flow
f)
Regulates flow rate by either
(1)Adjusting flow to within ± 5 drops per minute
of drops per minute
OR
IV.E.1.k
(2)Adjusting the flow rate of the infusion control
g)Records on the PCS Recording Form the new fluid
being administered
The preceding group of Critical Elements applies only if a new IV bag is to be
hung during your PCS. When a new IV needs to be hung, the CE will indicate this
in writing on the PCS Assignment Kardex. If the physician changes the order for
the IV solution during the PCS, your CE will ask you for your PCS Response Form
and change your assignment to reflect the change in the IV order.
The CE will designate on the PCS Assignment Kardex if you need to change the
IV tubing. You are to select the designated solution, so carefully check the label
on parenteral fluids. If you select the incorrect fluid the CE will stop you prior to
opening the parenteral fluid container and/or administration set(s). You will be
stopped at this point to save your patient from unnecessary charges.
Before hanging a new IV solution, identify your patient by checking the patient’s
ID band, and assess patency of the IV site. Then initiate and maintain the correct
rate. Document the new IV solution on the PCS Recording Form page of the
Student PCS Response Form under New Solution. The fluid intake from the
previous IV which has infused is recorded as “intake.” The volume left in the
bag before you changed it will be indicated by the CE on your PCS Kardex. You
would record as parenteral fluid intake the volume infused prior to you changing
the bag. You are not required to record any of the new solution as intake.
Document parenteral intake for a continuous IV only when you hang a new IV
solution or the IV is discontinued. The intake is recorded in the Parenteral Intake
section of the PCS Recording Form. If the primary IV is continuously infusing and
has not been interrupted, you are not required to record this as intake.
Case Study 1
When you begin the PCS there are 100 mls in the bag and the IV is
running at 125 mls per hour, you know that the IV fluid in that bag
will completely infuse during your PCS. When that happens, you would
count the 100 mls as intake on the PCS Response Form. However, you
would not count (or document) any fluid from the new bag that you
hang to maintain the continuous IV infusion.
Case Study 2
Let’s say the doctor wants the IV of D5W that is currently running to be
discontinued and the solution the doctor wants is D5 ½ strength normal
saline (NS). In this case, you would take the D5W down, hang the D5
½ strength normal saline (NS) and count as parenteral intake what has
been infused from the first IV (D5W) during your PCS time.
IV.E.1.l
5)When maintenance of an intermittent venous access
device is required:
a)Assesses the insertion site of peripheral, central,
or implanted venous access device for dislocation,
infiltration, or other complications by
1)Feeling the surrounding skin for changes
in temperature
OR
2)Palpating the surrounding tissue for edema
b)Aspirates for blood return prior to flush unless
contraindicated
c)Flushes the intermittent access device with the
designated flush solution
d)
Records the flush solution on PCS Recording Form
You should be familiar with techniques for flushing intermittent venous access
devices (IVAD). You will be oriented to specific hospital protocols, and the
written flush solution will be designated on your PCS Assignment Kardex.
Be sure to assess the IV insertion site prior to attaching the syringe with the
designated flush solution to the IVAD. If the IV site appears intact, gently
aspirate for blood return unless contraindicated, then push solution while
assessing for infiltration. If resistance is met, stop and report to the assigned
nurse. Gloves are worn when assessing the IV site as well as while flushing the
intermittent venous access device.
Document the assessment data related to the IV site and flush solution on the
PCS Recording Form page of the Student PCS Response Form.
6)
When a peripheral IV is to be discontinued:
a)
Assesses condition of IV site
b)
Removes the cannula
c)
Applies pressure to the venipuncture site
d)
Applies a protective covering
When assigned, discontinue a peripheral IV by removing the cannula, applying
pressure to the venipuncture site, and applying a protective covering.
Discontinuing an IV is a skill that can be added to your PCS Assignment during
the Implementation Phase. The CE will designate the type of protective covering
to be used following removal of the cannula. Assessment of the condition of the
IV site is to be recorded on the PCS Recording Form. Explaining your actions to
your patient during this or any other procedure facilitates a caring relationship.
IV.E.1.m
4 When enteral and/or parenteral intake is assigned
a.Measures the amount of fluid ingested/infused
b.
Records fluid intake within ± 10% of the actual intake
c.
Records the kind(s) of fluids ingested/infused
d.Records hourly intake on the PCS Recording Form within ± 10
minutes of the designated time, when hourly intake is assigned
When measurement of intake is assigned, you are to measure, not estimate,
oral fluids. Use measurement charts, available on hospital units, which list
containers and their fluid capacity to determine fluid intake. Measure all fluids
with a calibrated measuring instrument (e.g., clear plastic measuring container,
medicine cup, syringe) before the patient’s food tray is removed from the room.
The CE will provide you with a measuring device. Your CE will orient you to
Intake and Output (I&O) recording forms and the liquid measures used on the
hospital unit. For example, assume the volume of a coffee cup is 240 mls. Your
patient has ingested half of the cup of coffee. You would pour the remaining
coffee from the cup into a measuring device and subtract that amount (let’s
say it is 120 mls) from 240 mls. In this example you would record 120 mls as
enteral intake.
Intake you will be responsible to record includes:
• A
ll fluids consumed during the PCS, including the fluids on the breakfast
or lunch tray.
• T
he volume of the primary IV fluid infused during the PCS when the
primary IV fluid has totally infused and the next ordered solution is hung,
the IV orders are discontinued, or the patient is on hourly intake.
• The volume of a secondary IV when it has fully absorbed.
If an IV medication is hung during the PCS but is not absorbed before you enter
the Evaluation Phase, you should report to the assigned staff nurse that the
IV medication is still infusing. You are not required to include this fluid in the
patient’s parenteral intake.
If hourly intake is assigned, the CE will designate it on the PCS Assignment
Kardex. Record a correct hourly intake once during a PCS within ± 10 minutes
of the time designated by the CE.
IV.E.1.n
5. When output is assigned:
a.
Collects output
b.
Measures output during the entire PCS
c.Records amount of output within ± 10% of the actual output for
the PCS on the PCS Recording Form (output from urinary retention
catheters or other drainage apparatus is not measured during the
PCS unless otherwise designated)
d.Records amount of hourly output on the PCS Recording Form
within ± 10 minutes of the designated time when hourly output
is assigned.
When output is designated, you are to collect and measure all output. As with
intake, you will be allowed a 10% margin of error in documenting the output
during the PCS. Output to measure may include urine, liquid stool, emesis, chest
tube drainage, and/or wound or nasogastric secretions.
Measure output with a calibrated measuring instrument (i.e., a graduated
container or scale for weighing diapers). If you begin to discard the output prior
to measuring, the CE will stop you to prevent the output from being lost.
Drainage from indwelling Foley catheters, T-tubes, nasogastric tubes, and
gastrostomy tubes attached to continuous collection systems should not be
included in the calculation of the patient’s output unless the system is full, the
patient is on hourly output measurements, or you receive specific instructions
to do so. Colostomy and ileostomy output measurement may be assigned if
indicated clinically.
Weighing diapers
Weigh wet diapers when assigned in order to measure output in a child PCS.
It is important to remember to weigh diapers prior to discarding them. Once you
have discarded a diaper, it may not be retrieved. You may want to let the parents
know that you need to weigh the diapers to prevent them from discarding the
diapers. The CE will orient you to any hospital policy regarding the use of a
protective barrier, such as a paper towel and the scales to use for weighing
diapers. Check with the assigned nurse to learn whether formed stool is weighed
with the diaper. On some hospital units the formed stool is removed prior to
measuring the diaper weight.
You should be sure that a collection device is in place for a patient who is able
to get up to the bathroom.
IV.E.1.o
a.
Hydration status
b.Condition of insertion site for peripheral, central,
or implanted venous access devices.
Documentation for all assessment findings for Fluid Management is required for
successful completion of the CPNE. Document hydration status and the condition
of the IV site when the patient has an IV or maintenance of an intermittent
venous access (IVAD) device is assigned.
Examples of acceptable recording:
Enteral Intake
Type and Amount
Parenteral Intake
Type and Amount
Output
Type and Amount
Orange juice 120 ml
Coffee 240 ml
IVMB 50 ml
Urine
Liquid BM
Hydration Status
Skin Turgor
225 ml
435 ml
Parenteral Fluids
Current solution
D 5 ½ NS
OR
ICD setting 75 ml/hour
Mucous Membrane moist and intact
Condition of IV site
Temperature
OR
OR
Edema no edema
Fontanel
Example of what you might document in Narrative note under “Other Observations”
“Three watery green stools within two hour period; total measured 435 mls. Anal
region reddened and patient complained of soreness. Moisture barrier applied.”
11.When caring for an 86-year-old woman admitted in acute Congestive Heart
Failure (CHF) secondary to cardiac myopathy, your assignment includes
maintaining her IV of D5W NS @ 40 ml/hr by gravity flow (IV tubing gtt
factor is 10 gtts/ml), restricting oral fluids to 200 ml during the PCS, and
measuring intake and output.
a.
How would you proceed?
_________________________________________________________________________
_________________________________________________________________________
IV.E.1.p
b.
What should the IV flow rate be?
_________________________________________________________________________
_________________________________________________________________________
c.
How would you restrict the patient’s intake?
_________________________________________________________________________
_________________________________________________________________________
d.
What observations would be important in this situation?
_________________________________________________________________________
_________________________________________________________________________
12.When would you measure and record urine output if your assigned patient
has an indwelling urinary catheter?
_________________________________________________________________________
_________________________________________________________________________
13.What nursing diagnosis can you support with the data you have collected
during performance of the Critical Elements for Fluid Management?
_________________________________________________________________________
_________________________________________________________________________
14. How does the data you are collecting support your diagnoses?
_________________________________________________________________________
_________________________________________________________________________
15. What are some of the possible outcomes for a patient with these problems?
_________________________________________________________________________
_________________________________________________________________________
When caring for a 15-month-old admitted for dehydration due to diarrhea your
assignment includes fluid management. The IV is infusing at 35 ml/hr via an
ICD, and she is continuing to have diarrhea with occasional vomiting.
16. When would you assess urine output?
_________________________________________________________________________
_________________________________________________________________________
IV.E.1.q
17. How would you measure urine output?
_________________________________________________________________________
_________________________________________________________________________
18. What are some of the possible outcomes for this patient?
_________________________________________________________________________
_________________________________________________________________________
Fluid Management
Determine the significance of the following assessment findings and the nursing
actions you would take in response to such findings.
Assessment Finding
Significance
Nursing Action Required
1.
A bulging fontanel for an infant
Increased intracranial
pressure, fluid overload
Position infant upright.
Notify RN. Keep infant
quiet. Document your
findings.
2.
A depressed fontanel for an infant
Dehydration
Offer prescribed fluids.
Notify RN and document
your findings
3.
Skin tenting and moist oral mucus
membranes for an elderly patient
Normal in elderly
Continue to monitor
4.
Dry, flaky skin for a postoperative
patient who is taking clear liquids
May not be significant.
May be dehydrated or
have poor nutrition
Assess hydration status,
serum protein levels and
offer fluids
5.
No tenting, capillary refill <3 seconds.
Normal finding
Continue to hydrate
patient.
6. You enter an adult patient’s room, greet your patient and confirm their
identification. After washing your hands and putting on gloves, you assess
the IV site. You then verify the drip rate of a gravity flow IV or the ICD setting.
What if the ICD was set at the wrong rate?
Check your assignment to make sure you have the correct rate as written on your
Kardex assignment. Verbalize your finding to the CE. After you are sure of the correct
rate, set the ordered rate.
7. If the IV were running at 6 gtts/minute over the correct drip rate, what is the
potential consequence of administering excess fluid to the patient?
Fluid overload.
IV.E.1.r
8. If the IV was running at 6 gtts/minute less than the expected drip rate, what is
the possible consequence over a 24-hour period?
Patient’s fluid need would not be met, possibly leading to dehydration.
9. What could the consequences for a 6-year-old be if the IV drip rate was
inaccurate?
May experience fluid overload or dehydration more rapidly as infants/children do
not tolerate fluid volume excess or deficit as well as adults.
10. Why is there a margin of error in the CPNE for regulating fluids by gravity drip
is ± 5 gtts per minute?
The margin of error is allowed because the way the patient moves or positions their
arm can cause the IV to slow down or speed up.
11. When caring for an 86-year-old woman admitted in acute Congestive Heart
Failure (CHF) secondary to cardiomyopathy, your assignment includes
maintaining her IV of D5W @ 40 mls/hr by gravity flow (IV tubing gtt Factor is
10 gtts/ml), restricting oral fluids to 200 mls, during the PCS and measuring
intake and output.
a.
How would you proceed?
At the beginning of the Implementation Phase, wash your hands, introduce
yourself and complete the 20-minute Critical Elements under IV fluids.
b.
What should the IV flow rate be?
6 –7 gtts/min.
How would you restrict the patient’s intake?
c.
Note if the patient will be receiving a tray during your PCS. Find out how much
fluid she receives with her meals and medications.
d.
What observations would be important in this situation?
Assessment of hydration status, intake and output, breath sounds
and daily weight.
12. When would you measure and record urine output if your assigned patient has
an indwelling urinary catheter?
You would not need to measure it unless the Foley is discontinued, the patient is on
hourly intake and output or if you are assigned to empty it. This information would
be written on your assignment Kardex.
IV.E.1.s
13. What nursing diagnoses can you support with the data you have collected during performance of the Critical Elements for Fluid Management?
Examples might include: Excess Fluid Volume related to decreased Cardiac Output,
Activity Intolerance related to insufficient oxygen for activities of daily
living. Fluid Volume Deficit related to insufficient fluid intake.
14. How does the data you are collecting support your diagnoses?
Data that would support Excess Fluid Volume might include peripheral edema,
abnormal breath sounds, shortness of breath and weight gain. Data to support
the Diagnosis of Activity Intolerance might include dyspnea upon exertion, and/or
fatigue. Data that might support Deficient Fluid Volume Deficit could include: dry
oral mucous membranes, skin tenting, insufficient oral fluid intake, negative balance
of intake and output, increased serum blood urea nitrogen, weight loss.
15. What are some of the possible outcomes for a patient with these problems?
Examples of outcomes:
Excess Fluid Volume
• The patient will demonstrate normal breath sounds.
• The patient will demonstrate a decrease in peripheral edema.
• The patient will be able to increase activity level without dyspnea.
Activity Intolerance
• Patient will be able to perform ADLs without experiencing dyspnea.
• Patient will state ways to conserve energy.
Deficient Fluid Volume
• Patient will increase intake of fluid to a specified amount.
• Patient will demonstrate nontenting skin and moist oral mucous membranes.
IV.E.1.t
When caring for a 15 month old admitted for dehydration due to diarrhea, your
assignment includes fluid management. The IV is infusing at 35 ml/hr via an ICD,
and she is continuing to have diarrhea with occasional vomiting.
16. When would you assess urine output?
Each time the child voids.
17. How would you measure urine output?
Weigh diapers.
18. What are some of the possible outcomes for this patient?
Patient will not show signs of dehydration during PCS. Patient will tolerate sips
of fluid by end of the PCS.
IV.E.2.a
UNIT IV
Section E.2
Critical Elements for Vital Signs
1. Complies with established guidelines
2. Obtains accurate vital signs by
a.
Reading the instrument within a stated range of
1)
Counting within a stated range of
b.
± 0.2 degrees for temperature
1)± 5 beats/minute for apical or radial pulse
(± 10 beats/minute for apical pulse for a child under 2 years)
2)± 2 respirations/minute for adults
(± 6 respirations/minute for a child under 2 years)
Reading the instrument within a stated range of:
c.
1)
Obtaining an accurate weight when assigned by
d.
± 6 millimeters for blood pressure
1)
Balancing the scale
2)
Undressing the patient as necessary
3)
Maintaining cleanliness of the scale
4)
Weighing within one percent (1%) of the correct weight
e.
Obtaining oxygen saturation when assigned
f.
Assessing level of pain when assigned by
1)Asking an adult patient to rate level of pain using 0–10 scale
or visual analog scale
2)Asking a child to rate level of pain using a 0–5 faces scale
or age appropriate visual analog scale
OR
3)Using the FLACC pain assessment tool to rate level of pain for
a child ranging in age 2 months to 3 years of age
OR
OR
4)Observing behaviors indicative of pain in a patient unable
to rate his or her pain (e.g., moaning grimacing, clutching,
restlessness)
3. Records each of the assigned vital signs on the PCS Recording Form
IV.E.2.b
Vital Signs, always assigned are the measurement and recording of
temperature (T), pulse (P), and respirations (R). The measurement and
recording of blood pressure (BP), weight, oxygen saturation, and pain
level may be assigned. (Pain Level is not assigned in the same PCS as
Pain Management. Oxygen Saturation is not assigned as part of Vital Signs
if it is assigned in either Respiratory Assessment or Oxygen Management.)
Based on your patient’s needs you will be assigned temperature, radial or apical
pulse, blood pressure, weight, oxygen saturation, and/or pain level. The CE will
designate the vital signs to be measured on the PCS Assignment Kardex.
You will be taking the patient’s vital signs simultaneously with the CE. A double
stethoscope is provided for your use while taking the apical pulse and blood
pressure. It is up to you to initiate the use of the double stethoscope; the CE will
follow your lead. Report any deterioration of the patient’s clinical condition to
the patient’s assigned staff nurse as manifested in changes from the patient’s
baseline vital signs. Failure of the PCS will occur under Physical Jeopardy if
deterioration occurs and you do not report the change. Established guidelines
for taking vital signs include but are not limited to length of time to hold a
thermometer in place, size and position of the blood pressure cuff, the rate
of deflation of the BP cuff, and placement of a stethoscope for measurement
of apical pulse or avoiding the arm with the IV for BP measurement. Review
guidelines for taking vital signs in fundamentals of nursing texts or other
references listed.
Suggestions for Success:
• Write down baseline range of vital signs during the Planning Phase.
• A
llow patient to become comfortable with you, prior to taking vital signs.
You have until the end of the Implementation Phase to complete and declare
your complete set of vital signs.
• C
ount pulse and respirations for one full minute to eliminate the chance of
forgetting to multiply the count by the fraction of time used. Direct the count
by telling the CE that you will begin counting when the second hand on your
watch gets to the specific number determined by you. Count the first 2–3 heart
beats or breaths out loud to ensure that you and the examiner are starting at
the same time. Verbalize the word “Stop” upon reaching a full minute.
• If the radial pulse is irregular or difficult to obtain, invoke CDM and take an
apical pulse.
• M
easure the pulse, respirations, and blood pressure twice within close
time proximity before declaring your vital signs to validate accuracy of
your readings.
Required Areas of Care –Vital Signs
IV.E.2.c
• If you lose count or can’t hear let the CE know you need to begin again.
• W
hen an accurate reading of vital signs cannot be obtained (i.e., fussy child,
noisy room) verbalize to your CE that you will defer the measurement of
the vital signs until the situation has changed. You have until the end of the
Implementation Phase to complete and declare a complete set of vital signs.
• B
e sure the thermometer is placed properly in the axilla to obtain an accurate
axillary temperature.
• If pain assessment is assigned, make sure you assess the pain level before
declaring vital signs.
• Immediately write down the assessment values you obtain.
• Circle the values you are submitting as your final readings.
• P
ractice using the equipment required for obtaining vital signs during the unit
orientation.
Additional Suggestions When Caring for Children
• If a baby is restless, ask a family member to hold and comfort the baby while
you take the vital signs.
• M
aintain an accurate count of an infant’s apical pulse by tapping a finger
or foot in time with the beat.
• It may be easier to count respirations and pulse when the child is asleep.
• If you do not have access to children, use a dog or cat to practice counting
a rapid pulse.
2. Obtains accurate vital signs by
a.
1)
± 0.2 degrees for temperature
The CE will write the method for obtaining the patient’s temperature on the
PCS Assignment Kardex. Designated methods include oral, axillary, temporal,
tympanic, or rectal. During the unit orientation, the CE will orient you to any
equipment you will be using during the PCS. On many units the number of
thermometers is limited, and the CE may defer orientation until she is able to
obtain a thermometer.
Taking an oral or rectal temperature will place you at risk for body fluid
pathogen transmissions; therefore gloves are worn and Standard Precautions
maintained.
IV.E.2.d
b.
Counting within a stated range of
Prior to starting the count you should tell the CE the length of time to count
(e.g., 30 seconds, 1 minute). It’s to your advantage to count for a full minute.
Always count irregular pulses or respirations for one full minute.
For radial pulse, palpate the pulses in both wrists and use the wrist in which
you can find the pulse and feel the beat easily. Position yourself comfortably,
since standing in an awkward position for a full minute may be very uncomfortable and cause you to lose count. Feel the pulse for a few seconds before
beginning the count to become familiar with the rate and rhythm. While you
count the pulse on one wrist the CE will be palpating simultaneously on the
other wrist. The CE will have verified the equality of the pulses prior to the
beginning of the PCS. Electronic equipment may not be used for pulse
rate assessment. You are to palpate or auscultate the patient’s pulse.
c.
1)
± 6 millimeters for blood pressure
The size of the cuff in relation to the limb will effect BP readings, especially
with pediatric patients and very small or large adult patients. Both manual and
automated BP equipment are used. A manual cuff will be required of an adult
BP for at least the first PCS. The successful measurement of a manual blood
pressure reading is required prior to the use of automated BP equipment in an
adult PCS. When automated equipment is allowed, it is for the assessment of BP
only. In designating systolic and diastolic sounds for BP, the first sound and the
last sound are used. Either the bell or diaphragm of a stethoscope can be used
to auscultate the BP.
1.You are assigned a 7-month old with RSV whose vital signs are:
temperature 99.6 F (tympanic), apical pulse 120 beats/minute, respiratory
rate 24 breaths/minute. The information in the patient’s chart notes that
the previous vital signs were a temperature of 100.6 F (tympanic), apical
pulse 140 beats/minute, respiratory rate of 30 breaths/minute. What do
you need to consider before declaring your vital signs?
_________________________________________________________________________
_________________________________________________________________________
IV.E.2.e
2.Your patient’s baseline BP is 110–138/70–90. How high will you pump the
sphygmomanometer?
_________________________________________________________________________
_________________________________________________________________________
d.
Obtains accurate weight when assigned by
1)
Balancing the scale
2)
Undressing the patient as necessary
3)
Maintaining cleanliness of the scale
4)
Weighing within one percent (1%) of the correct weight
When obtaining the patient’s weight is assigned as part of Vital Signs you are to
balance the scale, undress the patient as necessary, maintain the cleanliness of
the scale, and record the weight obtained which must be within 1% of the correct
patient weight. Weight may be assigned in both child and adult PCSs. You should
be able to read the scale in pounds or kilograms.
Common reasons for failing this area include not balancing the scale prior
to weighing, not reading the scale accurately and weighing the patient after
breakfast. If you need to move the scale (i.e., from a utility room to the patient’s
room), you need to balance or zero the scale before weighing the patient.
Ask the assigned nurse to clarify any hospital-or unit-specific protocols (e.g.,
whether the children are weighed with any clothes/diapers, whether the weight
of the clothes/diapers is subtracted from the obtained weight, and the routine
time for weighing patients.
Maintaining cleanliness of the scale is done by 1) cleaning the weights and/or
scale after use and 2) using a barrier on the scale and between your hands and
the weights such as gloves or a paper towel. A barrier is not needed between
your hands and weights for an adult patient.
e.
Obtaining oxygen saturation when assigned
Oxygen (O2 ) saturation data is often collected with Vital Signs. As with all
equipment, the CE will orient you to the pulse oximeter used in the facility
where you will take the CPNE. Parameters are established as part of the unit
protocol. Values which need to be reported will be designated on the PCS
Assignment Kardex. As an example, the CE may write “Notify assigned nurse for
O2 saturation < 90%.” The patient would be placed in Physical Jeopardy if you did
not report values less than 90% in this case.
IV.E.2.f
f.
Assessing level of pain when assigned by
1)Asking an adult patient to rate level of pain using a
0–10 scale or visual analog scale
2)Asking a child to rate level of pain using a 0–5 faces scale
or age appropriate visual analog scale
OR
3)Using the FLACC pain assessment tool to rate level of pain
for a child ranging in age 2 months to 3 years of age
OR
OR
4)Observing behaviors indicative of pain in a patient unable
to rate his or her pain (e.g., moaning grimacing, clutching,
restlessness)
When designated, ask an adult or child patient to rate the level of pain or
observe behavior indicative of pain for the patient unable to rate his or her
own pain. Assess your patient’s level of pain using an appropriate rating scale
or assessment tool. If pain is assessed as part of Vital Signs, and you are not
assigned the Area of Care Pain Management, you are still responsible for
intervening in the management of your patient’s pain by reporting the pain
level to the staff nurse if indicated. Ignoring the patient’s report of increased
or unmanaged pain places the patient at risk for emotional and/or physical
jeopardy.
3. Records each of the assigned vital signs on the PCS Recording Form
Declaring the vital signs means you as the student are submitting your vital signs
measurement for comparison with the CE’s measurements.
After you have obtained a complete set of vital signs, the CE will ask, “Are you
ready to declare your vital signs?” If you have not already done so, verbalize to
the CE that you would like to take a second set of vital signs. After obtaining
those values, compare the first set to the second. Think about how the procedure
went. Could you hear well? Did you lose count? Did the valve release well?
If you had trouble obtaining any of the vital signs, you may ask to take a
particular reading a third time. Decide which readings to submit for evaluation.
Circle the readings on the PCS Recording Form and show them to the CE at that
time. It is acceptable to declare a part of the first and second set of vital signs
measurements. For example, the temperature and pulse can be declared from
the first set and the respirations, blood pressure, and oxygen saturation from
the second set.
IV.E.2.g
An example of Acceptable Documentation:
Vital Signs
1st Set
2nd Set
97.6
97.7
Pulse Rate
88
88
Respirations
16
18
Blood Pressure
140/180
142/80
Weight
168 lbs.
Temperature
Oxygen Saturation
97%
Pain Level
2/10
96%
Vital Signs
1. You are assigned a 7-month-old with RSV whose vital signs are: temperature
99.6º F (tympanic), apical pulse 120 beats/minute, respiratory rate 24 breaths/
minute. The information in the patient’s chart notes that the previous vital signs
were a temperature of 100.6º F (tympanic), apical pulse 140 beats/minute,
respiratory rate of 30 breaths/minute. What do you need to consider before
declaring your vital signs?
Determine if the pulse and respirations are normal for this age group and if the
temperature is normal for the technique used.
2. How high will you pump the sphygmomanometer?
According to the American Heart Association guidelines you pump the
sphygmomanometer 20–30 mm higher than the highest baseline systolic.
IV.E.2.h
IV.F
UNIT IV
Section F
Selected Areas of Care Related to Assessment
Selected Areas of Care are assigned as part of the PCS assignment based on the
patient’s health care needs.
The selected Areas of Care related to assessment include:
Skin Assessment
IV.F.1.a
UNIT IV
Section F.1
Critical Elements for Abdominal Assessment
1. Complies with the established guidelines
2. Positions the patient to facilitate abdominal assessment
3. Inspects for distention
4. Auscultates for bowel sounds over all 4 quadrants
5. Performs light palpation over all 4 quadrants for tenderness or rigidity
unless contraindicated
6. Measures abdominal girth when assigned
a.
Distention
b.
Presence or absence of bowel sounds in each of the 4 quadrants
c.
Tenderness or rigidity
d.
Abdominal girth, when assigned
Abdominal Assessment includes inspection, auscultation, light palpation,
and measurement of abdominal girth (when assigned).
1. Complies with the established guidelines
An example of established guidelines for abdominal assessment includes the
proper sequence: inspect (look), then auscultate (listen), palpate (feel), and
measure, if assigned.
2. Positions the patient to facilitate abdominal assessment
Provide privacy, use adequate lighting, and ensure that the patient is warm and
comfortable while performing the abdominal assessment. The CE will provide a
double stethoscope at your request when you are ready to auscultate for bowel
sounds. Improper positioning will result in incorrect assessment findings. Check
your patient’s position and comfort before beginning the abdominal assessment.
IV.F.1.b
Case Study
You are performing an abdominal assessment for a patient who is
s/p abdominal surgery. The original bulky surgical dressing is covering
the center of the abdomen from umbilicus to pubic bone. The patient
complains that it hurts to lie flat even after bending his or her knees
and asks to have the head of the bed raised. You acknowledge the
patient’s discomfort and tell the patient you will bring the head of
the bed up. You verbalize to the CE your plan to raise the head of the
bed up to less than 30 degrees from the horizontal and continue with
inspecting, auscultating, and lightly palpating the patient’s abdomen.
You are able to auscultate in all four quadrants even though the bulky
dressing covers most of the abdomen because you know a surgical
dressing does not contraindicate auscultation or palpation. It is possible
to auscultate and palpate all areas of the quadrant to the edge of the
dressing.
You are preparing to do an abdominal assessment for a 69-year-old patient
admitted to rule out acute appendicitis. During the report, you were told that the
patient has been complaining of severe right lower quadrant abdominal pain and
was just given a narcotic by injection.
1.What should you consider when doing the abdominal assessment? What is
the abdominal assessment sequence?
_________________________________________________________________________
_________________________________________________________________________
2.What is the importance of comparing your findings to the patient’s baseline
data you reviewed during the Planning Phase?
_________________________________________________________________________
_________________________________________________________________________
3. Inspects for distention
Once your patient is positioned, expose the entire abdomen for inspection.
Patient privacy is maintained. Exposing the patient unduly may place the patient
in Emotional Jeopardy.
As you inspect the patient’s abdomen, talk with the patient and parent (if the
patient is a child). Verbalize that you are observing the shape and contour of the
abdomen. In addition to comforting the patient by explaining nursing actions
to be taken, verbalizing the assessments you are performing will cue the CE to
what you are doing.
IV.F.1.c
4. Auscultates for bowel sounds over all 4 quadrants
When you are ready to auscultate the patient’s abdomen, ask the CE for the
stethoscope. The CE will listen through the double stethoscope with you.
Listen for bowel sounds in each of the four quadrants of the abdomen. If you
don’t hear any bowel sounds, glance at your watch because you will need to
listen for a minimum of 60 seconds per quadrant to distinguish whether bowel
sounds are absent or hypoactive. If you hear bowel sounds within the first
several seconds of listening, proceed to the next quadrant.
In order to determine whether bowel sounds are present or absent in a patient
who is on continuous gastric suctioning, turn off the suction machine while you
are auscultating for bowels sounds. This will enable you to hear the patient’s
bowel sounds without interference. If you do not turn off the suction machine
prior to auscultating, this would be a failure under Critical Element #1 “complies
with established guidelines.”
3.In each of these situations below decide what you would do if you received
the following baseline data and observed the corresponding data during the
abdominal assessment you performed
Baseline Data
Assessment Findings
Your Actions
67-year-old patient, s/p
appendectomy. NPO, bowel
sounds absent.
Abdomen soft, flat with bowel
sounds present in all 4 quadrants
3-month-old patient, s/p repair
of inguinal hernia. Bowel sounds
present in all four quadrants.
Abdomen soft, rounded with
bowel sounds present in all 4
quadrants.
8-year-old patient, admitted with
vomiting and severe abdominal
pain. Hyperactive bowel sounds.
Abdomen rigid and tender. Bowel
sounds absent.
5. Performs light palpation over all 4 quadrants for tenderness or rigidity
Palpation of all four (4) quadrants of the abdomen is the standard unless
contraindicated. If palpation is contraindicated, the CE will communicate this
to you by writing it on the PCS Assignment Kardex. Palpation is limited to light
abdominal palpation during the CPNE.
It is important to encourage the patient to try to relax abdominal muscles. Tense
or tight muscles hinder palpation. Warm hands promote relaxation.
IV.F.1.d
Ask the patient to report pain and identify any areas of tenderness prior to
beginning palpation, then palpate tender areas last. If your patient appears
distended or complains of fullness/discomfort, this may alert you to proceed
cautiously with light palpation.
You are about to perform light palpation of your patient’s abdomen when the
patient nervously tells you he is experiencing pain.
4.
What should you do?
_________________________________________________________________________
_________________________________________________________________________
6. Measures abdominal girth when assigned
When measuring abdominal girth is assigned, the CE will designate the
landmarks on the PCS Assignment Kardex. The CE will provide a tape measure
for you to use. Review textbooks for information about accurate placement of
the measuring tape around the abdomen (i.e., at the level of umbilicus).
a.
Distention
b.
Presence or absence of bowel sounds in each of the four quadrants
c.
Tenderness or rigidity
d.
Abdominal girth, when assigned
Include all assessment data related to contour, size, presence or absence
of bowel sounds in each of the four (4) quadrants, tenderness, rigidity, and
abdominal girth when recording your findings for the Abdominal Assessment
Area of Care.
Examples of Acceptable Recording:
“Abdomen flat and bowel sounds present in all four (4) quadrants, patient
complained of slight tenderness in lower left quadrant with light palpation.
Abdominal incision present with wound edges well approximated with
no redness or drainage noted.”
“Abdomen soft and non-rigid, non-distended, bowel sounds present in all
four quadrants. No pain on light palpation. Tolerated breakfast without nausea.”
“Abdomen flat, slightly rigid. Bowel sounds hypoactive in all four (4) quadrants,
stoma in right lower quadrant red. Ostomy appliance securely adhered to skin,
no leaking. Abdominal incision intact, no redness or drainage noted.”
IV.F.1.e
1. You are preparing to do an abdominal assessment for a 69-year-old patient
admitted to rule out acute appendicitis. During the report, you were told that the
patient has been complaining of severe right lower quadrant abdominal pain and
was just given a narcotic by injection. What should you consider when doing the
abdominal assessment?
Wait 20 to 30 minutes to allow medication to take effect. Once the patient is
comfortable being positioned flat for the assessment, you would first inspect the
abdomen for size, shape, incisions or any abnormal bulges or skin rashes/lesions.
You would then listen in each of the four (4) quadrants until you hear bowel sounds.
If you do not hear bowel sounds you must listen at least for one minute in each
quadrant before you can declare there are no bowel sounds. Perform light palpation
in all four (4) quadrants for any masses, tenderness or rigidity. If assigned, measure
the abdominal girth. Record all of the assessment findings.
2. What is the importance of comparing your findings to the patient’s baseline data
you reviewed during the Planning Phase?
It is important to know the baseline data so that you can report any deviation that
could be harmful to the patient.
3. For each situation below decide what you would do if you receive the following
baseline data and observed the corresponding data during the Abdominal
Assessment you performed.
Baseline Data
Assessment Findings
Your Actions
67-year-old patient, s/p
appendectomy. NPO, bowel
sounds absent.
Abdomen soft, flat with bowel
sounds present in all 4 quadrants
Document on PCS Recording
Form, report to primary nurse
and continue to monitor.
3-month-old patient, s/p repair
of inguinal hernia. Bowel sounds
present in all four quadrants.
Abdomen soft, rounded with
bowel sounds present in all 4
quadrants.
Document and continue to
monitor.
8-year-old patient, admitted with
vomiting and severe abdominal
pain. Hyperactive bowel sounds.
Abdomen rigid and tender. Bowel
sounds absent.
Immediately report to primary
nurse. Keep NPO. Document
your findings.
4. You are about to perform light palpation of your patient’s abdomen when the
patient nervously tells you he is experiencing pain. What should you do?
Check MAR to see when last pain medication was given. If the patient is in pain and
can not be medicated in time for you to perform light palpation, invoke CDM saying,
I am not going to palpate because the patient is too uncomfortable and can not
tolerate palpation, or if the patient refuses to allow you to complete the Abdominal
Assessment.
IV.F.1.f
IV.F.2.a
UNIT IV
Section F.2
Critical Elements for Neurological Assessment
2. Assesses the patient’s level of consciousness by
a.Asking specific questions to determine orientation to all of the
following:
1)
Time
2)
Place
3)
Person
b.Determining the patient’s ability to recognize familiar people
or common objects in the environment
OR
OR
c.Presenting visual, auditory, and tactile stimuli to a child between
1 and 3 years of age or a noncommunicating child or adult
3. Palpates the anterior fontanel of a child under 1 year of age, with the
child in an upright position, unless contraindicated
4. Assesses pupillary response regarding:
a.
Equality of pupil size
b.
AND
Reaction to light
5. Assesses equality of motor response in upper and lower extremities in a
responsive patient by
a.
Asking the patient to
1)
Use both hands to squeeze student’s hands simultaneously
2)
AND
Dorsiflex or plantarflex both feet simultaneously
OR
IV.F.2.b
b.Observing musculoskeletal response(s) in a child under 3 years of
age or a noncommunicating child or adult for
1)
2)
Symmetry
AND
Movement
6. Assesses the patient’s response to a noxious stimulus when the patient
is nonresponsive to verbal stimuli by applying pressure to a nailbed
a.
Level of consciousness
b.
Assessment of fontanel
c.
Pupillary response
d.
Equality of motor response
e.
Response to noxious stimuli
Neurological Assessment is the assessment of neurological status
including level of consciousness, equality of pupil size and reaction to
light, sensory motor responses, and palpation of the anterior fontanel in
a child under 1 year of age. (The Braden Scale is not to be assigned in
the same PCS with Neurological Assessment.)
As a selected Area of Care, Neurological Assessment will be assigned for a
patient who has a need for monitoring of neurological status.
When Neurological Assessment is designated as part of your assignment,
assessments include level of consciousness, equality of pupil size and reaction
to light, equality of motor response, and response to a noxious stimulus when
the patient is nonresponsive to verbal stimuli. For a child less than one year old,
palpate the anterior fontanel.
1.What type of patient would require monitoring of neurological status and
might possibly be assigned for a PCS?
_________________________________________________________________________
_________________________________________________________________________
IV.F.2.c
2. Assess the patient’s level of consciousness by
a.Asking specific questions to determine orientation to all of the
following:
1)
Time
2)
Place
3)
Person
b.Determining the patient’s ability to recognize familiar people or
common objects in the environment
OR
OR
1 and 3 years of age or a noncommunicating child or adult.
To successfully complete the Critical Elements for “assesses the patient’s level
of consciousness,” ask the patient questions to determine orientation to person,
place, and time or determine your patient’s ability to recognize familiar people
or common objects in the environment. For the noncommunicating adult or
child between the ages of 1 and 3, you may present visual, auditory, and tactile
stimuli. For a child under the age of one you can observe how they react to the
presence of a familiar person (i.e., parent or guardian) or a familiar object such
as a toy. Review the patient care record to establish your patient’s baseline data
with which you can compare the results of your assessment.
Examples of a noncommunicating or nonverbal child or adult may include:
• A patient with a tracheostomy
• A patient with aphasia following CVA
• An unconscious patient
• A patient with a severe developmental delay
Patient’s who are nonresponsive to verbal stimuli require further assessment
of level of consciousness using noxious stimuli. Noxious stimuli is defined as
irritating physical sensations used to elicit a response. They may or may not
be painful. The assigned nurse and the clinical record will indicate to you the
noxious stimuli used to assess the patient’s response.
IV.F.2.d
2.You are told in report that the patient’s neurological status has been stable
for the past 48 hours and that she has had a difficult time sleeping since
being hospitalized. You perform all of the assigned Areas of Care except
Neurological Assessment. As you are documenting your findings for the
other assigned Areas of Care, your patient falls asleep. What should you do?
_________________________________________________________________________
_________________________________________________________________________
3.Palpates the anterior fontanel of a child under 1 year of age, with the
child in an upright position, unless contraindicated.
Palpate the anterior fontanel of a child under one year of age, with the child
in the upright position. The fontanel is assessed for bulging, depression, and
flatness. As an infant grows, the expanding head size reflects the growth and
differentiation of the nervous system. However, increased intracranial pressure
(ICP) may cause widening of the suture lines and bulging of the fontanel.
Therefore, assessment and documentation of the status of the anterior fontanel
is a required assessment of neurological status for an infant. Laying an infant
down may cause temporary bulging of the fontanel. Assess the anterior fontanel
with the infant’s head elevated greater than 30 degrees. If you have already
assessed the anterior fontanel for fluid management it is not necessary to
reassess again for neurological assessment.
4. Assesses pupillary response regarding
a.
Equality of pupil size
b.
AND
Reaction to light
Determine equality of the patient’s pupil size and assess the patient’s pupillary
reaction to light in a darkened room. Although an overhead light may be
available, use a flashlight to elicit pupillary response during the CPNE. You may
ask the CE for a flashlight if one is not readily available. There is no need to
bring a flashlight with you to the examination.
5. Assesses equality of the motor response in upper and lower extremities
in a responsive patient by
a.
Asking the patient to
1)
Use both hands to squeeze student’s hands simultaneously
AND
2)Dorsiflex or plantarflex both feet simultaneously against
resistance
IV.F.2.e
OR
b.Observing musculoskeletal response(s) in a child under 3 years
of age or a noncommunicating child or adult for
1)
2)
Symmetry
AND
Movement
6. Assesses the patient’s response to a noxious stimulus when the patient
is nonresponsive to verbal stimuli by applying pressure to a nailbed
While having the patient squeeze your hand or dorsiflex/plantarflex against
resistance, evaluate equality of motor response. Simultaneous bilateral
assessment allows for an accurate comparative measurement of motor
response. When the patient is unable to follow commands to perform the above
assessment, e.g., a child under the age of 3 or a noncommunicating child or
adult, equality of motor response can be evaluated by observing symmetry
and movement of the body. Symmetry is a correspondence in size and relative
position of parts on opposite sides of the body. Asymmetry such as with
paralysis (e.g., sagging of facial muscles) is an important assessment finding
for Neurological Assessment.
a.
Level of consciousness
b.
Assessment of fontanel
c.
Pupillary response
d.
Equality of motor response
e.
Response to noxious stimuli
Documentation of Neurological Assessment will be done by narrative note.
Document assessment data about level of consciousness such as, orientation
to person, place, and time or ability to recognize familiar persons or objects.
Documentation of your findings about equality of motor response for bilateral
hand squeeze and dorsi-plantar flexion motion or observation of symmetry of
motion will also be required. For pupillary response it is acceptable to use PERRL
for pupil equality and reaction to light. If the patient is not responsive to verbal
stimuli or touch, record assessment data about the patient’s response to noxious
stimuli.
IV.F.2.f
Examples of acceptable recording include the following:
“Alert and oriented to person, place, and time. Behavior appropriate to situation.
Pupils equal and reactive to light. Hand grasps and plantar flexion strong and
equal. No paresthesia. Verbalization clear and understandable.”
“Patient oriented to person and place, disoriented to time. Left pupil smaller
than right; both pupils brisk in response to light. Patient moves all extremities
spontaneously and has equal strength for hand grasps and plantar flexion.”
“Infant active & alert; responds to parents, verbal, and tactile stimuli with
bubbling noises and cooing. Anterior fontanel soft, slightly rounded. Pupils equal
and reactive to light, both eyes track light. Moves all four extremities equally and
spontaneously.”
3.For the following example, determine the reason the recording is
considered incomplete. Rewrite the nurse’s note so that it would be
acceptable for documentation of Neurological Assessment for the CPNE.
“No findings of neurological deficits; Neurocheck done, right side weaker
than left.”
_________________________________________________________________________
_________________________________________________________________________
4.You are to perform a Neurological Assessment. Your 10-year-old patient
starts to have a seizure and is demonstrating tonic movements of all four
extremities. What actions should you take? What information should you
provide the assigned nurse?
_________________________________________________________________________
_________________________________________________________________________
IV.F.2.g
1. Think about the patients you have taken care of. What type of patient would
require monitoring of neurological status and might possibly be assigned for
a PCS?
Possible patient selection might include a patient who has had a cerebral vascular
accident, head trauma, lead poisoning or a brain tumor.
You are told in report that the patient’s neurological status has been stable for the
past 48 hours and that she has had a difficult time sleeping since being hospitalized.
You perform all of the assigned Areas of Care except Neurological Assessment.
As you are documenting your findings for the other assigned Areas of Care, your
patient falls asleep.
2. What should you do?
Even though this patient has been stable for 48 hours and has not been sleeping
well, it would not be appropriate to omit the Neurological Assessment because
sleepy, drowsy behavior might indicate a change in the patient’s neurological status.
Perform the Neurological Assessment.
For the following example, determine the reason the recording is considered
incomplete. Rewrite the nurse’s note so that it would be acceptable for documentation
of Neurological Assessment for the CPNE.
3.“No findings of neurological deficits; Neurocheck done, right side
weaker than left.”
Patient alert and oriented to time, place and person. PERRL. Left upper and lower
extremities are strong against resistance and move freely on command. Right upper
and lower extremity flaccid.
4. As you begin the Neurological Assessment, your 10-year-old patient starts to
have a seizure, with tonic movements of all four extremities. What actions
should you take? What information should you provide the assigned nurse?
Stay with patient until seizure is over. Assure that the patient environment keeps
the patient safe, then immediately report to the assigned nurse and document your
findings. Describe how the child was just before, during and after the seizure.
IV.F.2.h
IV.F.3.a
UNIT IV
Section F.3
Critical Elements for Peripheral Vascular Assessment
2. Compares the extremities by all of the following methods:
a.
Palpating for the presence or absence of the most distal pulses
b.
Comparing the most distal corresponding palpable pulse(s)
c.
Assessing perfusion of extremity(ies) by
1)
checking capillary refill
OR
2)
d.
Assessing for temperature of extremity(ies)
e.Eliciting the patient’s response to tactile stimuli applied to the
distal portion of the extremity(ies)
f.
observing color
Assessing motor function by
1)
Asking the patient to move extremity(ies)
OR
2)Noting movement of the extremity(ies) in a child under 3
or a non-communicating adult
3. Records comparison of data related to bilateral extremities
a.
Presence or absence of the most distal pulses
b.
Capillary refill or color
c.
Temperature of extremity(ies)
d.
Response to tactile stimuli
e.
Motor function
Peripheral Vascular Assessment is the assessment of temperature,
perfusion, pulse, sensation, and movement in patients with casts, traction,
or peripheral vascular impairment. When possible, this assessment would
include a comparison of extremities.
IV.F.3.b
1.List the types of patients who would require assessment of localized blood
flow to the extremities as part of their plans of care.
______________________________________________________________________________
______________________________________________________________________________
2.Identify the indicators for assessing local blood flow and the physiological
reasons peripheral vascular assessment is needed.
______________________________________________________________________________
______________________________________________________________________________
3.What nursing diagnosis might relate to a patient who requires assessment
of the peripheral vascular system?
______________________________________________________________________________
______________________________________________________________________________
4.Write a measurable outcome and two interventions for nursing
diagnosis selected.
______________________________________________________________________________
______________________________________________________________________________
1. Complies with established guidelines.
2. Compares the extremities by all of the following methods:
a.
Palpating for the presence or absence of the most distal pulses
b.
Comparing the most distal corresponding palpable pulse(s)
Palpate for the presence or absence of the most distal pulse in each extremity,
and then compare the quality of the most distal pulses. Patients with impaired
tissue perfusion may not have palpable pulses. Assessment of perfusion in these
patients is an important nursing action. If it is necessary to use an amplification
device (such as a Doppler) to assess the pulses, the CE will provide this equipment and write “may use Doppler” on the PCS Assignment Kardex. In addition,
if it is known that pulses are not palpable at the dorsal-pedal site, the CE will
indicate that on the PCS Assignment Kardex. If the pulse is not palpable at the
dorsal-pedal site in one leg, you still are expected to palpate for the presence or
absence of the dorsal-pedal pulse on the intact leg. Then compare the quality
of the most distal corresponding pulses. When comparing the pulses, you can
palpate each one individually, but it is preferable to palpate the pulses simultaneously. When appropriate, you can request a Doppler if you are having difficulty
palpating a pulse.
IV.F.3.c
5. Compare and contrast assessment findings in arterial and venous insufficiency.
Arterial
Venous
____________________________________ _____________________________________
____________________________________ _____________________________________
6. How will knowing the difference between arterial and venous insufficiency help
you anticipate assessment findings during peripheral vascular assessment?
______________________________________________________________________________
______________________________________________________________________________
7. How will you assess the most distal pulses for a patient who has a partial foot
amputation or an above-the-knee amputation?
______________________________________________________________________________
______________________________________________________________________________
c.
Assessing perfusion of extremity(ies) by
1)
Checking capillary refill
2)
OR
Observing color
Compare the assigned extremities bilaterally. Assessment of perfusion can be
performed by checking capillary refill or observing color. Capillary refill normally
takes less than three seconds. Assessment of perfusion of the extremities may
be done during another Area of Care; e.g., Skin Assessment. If you choose to
complete Critical Elements from two Areas of Care at the same time, it will be
helpful to verbalize this to the CE at the time you are doing so. For example,
while you are checking for edema, say “I am checking the perfusion of the lower
extremities now.”
d.
Assessing for temperature of extremity(ies)
Assess temperature by touching the assigned extremities. It is important to
verbalize your findings as an alert to the CE that you have noted the temperature
of the assigned extremity.
IV.F.3.d
8.In the following situations, what would you do to complete the Critical
Elements for assessing capillary refill and temperature?
How to implement, modify,
or omit Critical Elements
Rationale
The patient has a bulky surgical
dressing from hip to toe.
The patient has a cast.
The patient is OOB in a chair with
orthopedic shoes on.
The patient is in traction.
What other situation can you
anticipate? Please specify.
9.You are required to do a Peripheral Vascular Assessment on a 64-year-old
patient who is s/p abdominal aortic aneurysm repair. Your findings indicate
that the left leg is slightly cooler then the right leg and that there is no
palpable dorsal pedal pulse on the left foot.
What do your assessment findings suggest?
_________________________________________________________________________
_________________________________________________________________________
10.You are caring for a 6-month-old who is admitted with a diagnosis of
coarctation of the aorta, and is awaiting surgery. One of the assigned Areas
of Care is Peripheral Vascular Assessment. Your assessment indicates
decreased pedal pulses and capillary refill >3 seconds in both lower
extremities.
What do these findings suggest?
_________________________________________________________________________
_________________________________________________________________________
e.Eliciting the patient’s response to tactile stimuli applied to the
distal portion of the extremity(ies)
Ask the patient whether he or she feels your touch on the toes or fingers.
A patient’s verbalization of pain in an extremity(ies) is not sufficient to
complete Critical Element #1e. A patient may be experiencing pain in a
limb, but not be able to feel stimuli applied to the extremity.
f.
IV.F.3.e
Assessing motor function by
1)
Asking the patient to move extremity(ies)
OR
or a non-Communicating adult.
To assess motor function, you either ask the patient to move the most distal
portion of the assigned extremities or observe movement of the extremities
in a child under three years old or in a noncommunicating adult.
3. Records data related to bilateral comparison of extremities
a.
Presence or absence of the most distal pulses
b.
Capillary refill or color
c.
Temperature of extremity(ies)
d.
Response to tactile stimuli
e.
Motor function
Document assessment data for the comparison of the assigned extremities,
including presence or absence and equality of the most distal pulses, capillary
refill, temperature, response to tactile stimuli, and movement. If you are
documenting your assessment findings and you realize you have omitted one
of your assessments, notify the CE that you would like to return to the patient’s
room to complete this Area of Care. If you need to re-enter the patient’s room
and initiate patient care, remember that the Critical Elements for the overriding
Areas of Care are still in effect throughout the entire PCS.
• “ Left and right lower extremities have palpable and equal pedal pulses.
Capillary refill less then 3 seconds in both extremities. Temperature
warm to touch in both feet. Toes of both feet were wiggled simultaneously upon command. Patient states that she feels touch in multiple
areas of both feet.”
• “ Left foot has audible pedal pulse via Doppler, right foot pedal pulse
palpable. Capillary refill less than 3 seconds in left foot and greater then
3 seconds in right foot. Left foot cooler than right foot to touch. Patient
states that she can feel sensation in toes of both feet except for left great
toe which is numb; can wiggle toes without difficulty on both feet.”
IV.F.3.f
11.In the following examples, score the documentation using the Critical
Elements. Decide if the student would successfully complete Critical
Element 3. If not, what would need to be added to meet the minimum
standard set in the Critical Element? What is the importance of including
that data?
Sample Documentation
Critical Elements met
Yes/No
To meet Critical
Elements, must include
the following:
Importance of
including this data
Right lower leg red,
warm, and tender to
touch. Circumference of
right leg 16" and left leg
14". Patient instructed to
remain in bed.
Radial pulses equal
and easily palpable
bilaterally. Capillary
refill < 3 seconds. Hands
warm to touch. Patient
moves all fingers at will
and responds to tactile
stimuli to both hands.
Full leg cast remains
intact to left leg. Color
pink, able to wiggle
toes, able to feel light
touch. Toes warm.
IV.F.3.g
1. List the types of patients who would require assessment of localized blood flow
to the extremities as part of their plan of care.
Examples of patients who might be selected for your assignment include those
individuals with Peripheral Vascular Disease, Diabetes Mellitus, Congestive Heart
Failure, fractures and those requiring orthopedic surgery.
2. Identify the indicators for assessing local blood flow and the physiological
reasons Peripheral Vascular Assessment is needed.
Indicators: Changes in color, temperature, presence of pain, decrease in
distal pulses.
Rationale: When there is a decrease in arterial blood flow there is a decrease in
tissue perfusion, eventually resulting in tissue necrosis.
Indicators: Venous insufficiency is manifested by edema of the affected extremity,
rubor and ulceration.
Rationale: When there is a decrease in venous return there is pooling of blood in
the extremity resulting in poor tissue perfusion eventually resulting in ulceration.
3. What nursing diagnosis might relate to a patient who requires assessment of the
peripheral vascular system?
1.Ineffective Peripheral Tissue Perfusion related to compromised blood flow as
evidenced by pale, cool extremities.
2.Acute Pain related to decrease tissue perfusion as evidenced by (AEB) patient
states a pain level of 7 on the pain rating scale.
4. Write a measurable outcome and two interventions for the nursing diagnosis
selected.
Diagnosis: Ineffective Peripheral Tissue Perfusion
Outcome: Patient will identify factors that improve peripheral circulation.
1.
Intervention: Assess the patient’s understanding of what causes decreased blood flow to their extremities.
2.
Intervention: Teach patient ways to improve circulation to extremity.
IV.F.3.h
Diagnosis: Acute Pain
Outcome: Patient will rate pain at or < 3 on a scale of 0−10.
1.
Intervention: Reposition patient.
2.
Intervention: Keep leg(s) in a dependent position if the patient has
arterial insufficiency, elevate legs if the patient has venous insufficiency.
Note: Only 1 of these interventions would be appropriate to a particular
patient.
5. Compare and contrast assessment findings in arterial and venous insufficiency.
Arterial
Pulses diminished, no edema, cool temperature, pain, intermittent claudication,
(may increase with elevation), decreased sensation, may have tingling.
Venous
Pulses present, edema improves with elevation, normal or slightly warmer
temperature, pain decreases with elevation and exercise, may have pruritus.
6. How will knowing the difference between arterial and venous insufficiency help
you to anticipate findings during Peripheral Vascular Assessment?
The nursing interventions are different depending on whether the insufficiency is
arterial or venous. If it is arterial there is a decrease in oxygenated blood flow to
the extremity and there will be tissue death if this is not corrected. You would then
position the leg in a dependent position to increase arterial blood flow. When there
is venous insufficiency, there is a decrease in venous return to the heart resulting
in edema and subsequent ulceration. You would elevate the leg to increase return
blood flow.
7. How will you assess the most distal pulses for a patient who has a partial foot
amputation or an above the knee amputation?
You would assess the most distal pulse in each extremity, then compare the most
distal corresponding pulses. Partial foot amputation: compare the bilateral posterior
tibial pulses. Above the knee amputation: compare the bilateral femoral pulses.
IV.F.3.i
8. In the following situations what would you do to complete the Critical Elements
for assessing capillary refill and temperature?
How to implement, modify,
or omit Critical Elements
Rationale
The patient has a bulky surgical
dressing from hip to toe.
If toes are not completely
encased in the dressing you
can still assess the nail beds for
capillary refill.
You need to assess the most
distal portion of the foot to
ensure there is adequate tissue
perfusion.
The patient has a cast.
If toes are not covered, assess
as you would normally.
Cast may be too tight impeding
blood flow to toes.
The patient is OOB in a chair with
orthopedic shoes on.
Remove shoes to assess toes.
Adequate assessment can not
be done with shoes on.
The patient is in traction.
Assess most distal pulses.
To ensure adequate perfusion
of extremity.
What other situation can you
anticipate? Please specify.
9. You are required to do a Peripheral Vascular Assessment on a 64-year-old
patient status post abdominal aortic aneurysm repair. Your findings indicate that
the left leg is slightly cooler than the right leg and there is no palpable dorsal
pedal pulse on the left foot.
What do your assessment findings suggest?
Decreased tissue perfusion of the left extremity.
In the following examples, score the documentation using the Critical Elements.
Decide if the student would successfully complete Critical Elements. If not, what
would need to be added to meet the minimum standard set in the Critical Element?
10. You are caring for a 6 month old that is admitted with a diagnosis of coarctation
of the aorta, and is awaiting surgery. One of the assigned Areas of Care is
Peripheral Vascular Assessment. Your assessment indicates decreased pedal
pulses and capillary refill > 3 seconds in both lower extremities. What do these
findings suggest?
These are normal findings for an infant with coarctation of the aorta. With this
condition decreased pedal pulses and slow capillary refill is expected.
IV.F.3.j
11.
Right lower leg red,
warm, and tender to
touch. Circumference of
right leg 16" and left leg
14". Patient instructed to
remain in bed.
Radial pulses equal
and easily palpable
bilaterally. Capillary
refill < 3 seconds. Hands
warm to touch. Patient
moves all fingers at will
and responds to tactile
stimuli to fingers of
both hands.
Full leg cast remains
intact to left leg. Color
pink, able to wiggle
toes, able to feel light
touch. Toes warm.
Critical Elements met
Yes/No
To meet Critical
Elements, must include
the following:
Importance of
including this data
No
Moves toes of both
feet on command.
Pedal pulses equal
and strong, able to
identify areas touched
on toes of both feet.
Data related to left
leg in regard to temperature, color, and
capillary refill.
May indicate
inadequate perfusion
of the lower extremity.
Yes
N/A
N/A
Data related to right
leg, pulse and movement of left leg.
To determine what is
normal for the patient,
the affected extremity
needs to be compared
to the unaffected
extremity.
No
IV.F.4.a
UNIT IV
Section F.4
Critical Elements for Respiratory Assessment
2. Positions the patient to facilitate assessment
3. Assesses the patient’s respiratory status by
a.Instructing the patient specifically to breathe in and out as
deeply as possible.
b.Auscultating breath sounds over upper and lower lobes by
systematically moving the stethoscope from side to side
c.
Observing breathing patterns
d.
Measuring oxygen saturation when assigned
a.
Comparison of breath sounds bilaterally
b.
Abnormal breathing patterns
c.
Oxygen saturation when assigned
Respiratory Assessment is the assessment of breath sounds and breathing
patterns to determine respiratory status. (Respiratory Assessment will
not be assigned in the same PCS with Respiratory Management. Oxygen
Saturation, if assigned in Respiratory Assessment, will not be assigned in
the same PCS with either Vital Signs or Oxygen Management.)
Respiratory Assessment is assigned as a Selected Area of Care for any patient
who requires monitoring of respiratory status. Respiratory Assessment will not
be assigned with Respiratory Management since the Critical Elements for these
Areas of Care duplicate each other.
An example of “complies with established guidelines” within the Respiratory
Assessment Area of Care includes listening over intercostal spaces rather than
over bony surfaces and systematically moving the stethoscope from side to side
to allow for comparison of one lung field to the comparable lung field on the
opposite chest wall.
IV.F.4.b
2. Positions the patient to facilitate assessment
During Respiratory Assessment, the patient should be in an upright position
unless contraindicated. For patients who are unable to sit upright but can turn,
the side lying position is acceptable. It is acceptable to auscultate the anterior
chest wall for patients who are unable to turn or sit up.
3. Assesses the patient’s respiratory status by:
a.Instructing the patient specifically to breathe in and out
as deeply as possible
c.
d.
Measuring oxygen saturation when assigned
When you are ready to begin listening to breath sounds, ask your CE for the
stethoscope. Instruct the patient to breathe in and out as deeply as possible.
In the case of an infant or younger child, you may auscultate breath sounds
while they are asleep, or being held by a parent. Position yourself so you can
comfortably hear and see what you are doing. Palpate to identify the location
of ribs and intercostal spaces.
Case Study
You are caring for a patient who is recovering from a spinal anesthesia.
The physician’s order states “Head of bed elevated no greater than
15 degrees.” You invoke CDM by verbalizing to the CE that breath
sounds cannot be auscultated with the patient in an upright position,
so you will assess the patient’s respiratory status with the head of the
bed elevated no greater than 15 degrees.
IV.F.4.c
a.
Comparison of breath sounds bilaterally
b.
c.
Oxygen saturation when assigned
Assessment of the patient’s breathing pattern (rhythm, depth, and use
of accessory muscles) is documented in your narrative note.
Document data related to breath sounds heard, abnormal breathing patterns
observed, and oxygen saturation level when assigned. Your recorded assessment
data about breath sounds reflects the comparison of lung sounds bilaterally.
Distinguish between normal and abnormal breath sounds and record these
findings. You are not expected to distinguish one particular abnormal breath
sound from another.
• “ Shallow respirations at rest, breathing pattern regular with no apparent
discomfort on inspiration or expiration. Breath sounds clear bilaterally
in upper and lower lobes.”
• “ Respirations rapid with an irregular breathing pattern, bilateral breath
sounds abnormal in lower lobes, upper lobes clear; O2 saturation 90%
on 2L nasal cannula. Patient states “ I have trouble catching my breath.”
• R
espiratory assessment of an infant: “Intercostal retractions noted;
breathing pattern regular. Breath sounds clear bilaterally in upper and
lower lobes, O2 saturation 97% on room air.”
IV.F.4.d
IV.F.5.a
UNIT IV
Section F.5
Skin Assessment
Critical Elements for Skin Assessment
1. Assesses, from the list below, a minimum of two vulnerable skin
surfaces including any designated area(s) for:
a. color changes
c. temperature
d. edema
e. moisture (e.g., perspiration, incontinence, diarrhea,
heels
sacral/coccyx
occiput
trochanter
skinfolds
peri anal
designated area
2. Records assessment data of two vulnerable skin surfaces including any
a. color changes
c. temperature
d. edema
IV.F.5.b
1. Assesses, from the list below, a minimum of two vulnerable skin
surfaces including any designated area(s) for:
a. color changes
c. temperature
d. edema
heels
sacral/coccyx
occiput
trochanter
skinfolds
peri anal
designated area
Any skin surface or surfaces that are at risk for pressure ulcer formation should
be assessed. Conduct your assessment by inspecting and palpating the skin. Your
assessment may reveal lesions, bruising, purpura, rashes, lacerations, shearing
of skin, edema, and moisture from perspiration or incontinence. While the
presence for edema may be measured on a scale of 1– 4, for the purposes of the
examination you are only expected to assess and document either the presence
or absence of edema.
Adult and pediatric patients who are bedridden or confined to a wheelchair are
at greater risk for alterations in skin integrity than patients who are ambulatory.
Therefore, you will be expected to base the extensiveness of the skin assessment
on your patient’s risk for alteration in skin integrity. Assess a minimum of
two vulnerable skin surfaces including any designated area(s). Perform a
skin assessment appropriate to the patient’s clinical condition that meets the
requirements of the Critical Elements.
IV.F.5.c
2. Records assessment data of two vulnerable skin surfaces including any
a. color changes
c. temperature
d. edema
Document data related to each of the above assessment findings for Skin
Assessment which include: the skin surfaces assessed, color of the patient’s skin,
its integrity, temperature, and presence or absence of edema and moisture.
Example of an acceptable recording:
“Skin over lower posterior body surface is pale pink, and warm to touch, no
edema noted. Skin is intact with a reddened area on coccyx, moisture noted
in skin folds of buttocks. Skin folds washed with water and dried, patient
repositioned on left side off coccyx.”
IV.F.5.d
IV.G
UNIT IV
III
Section G
A
Selected Areas of Care Related to Management
Selected Areas of Care are assigned as part of the PCS assignment based on the
Patient’s health care needs.
The selected Areas of Care related to management include:
Comfort Management
Oxygen Management
Pain Management
Wound Management
Remember: Assess-Implement-Reassess for all management Areas of Care
IV.G.1.a
UNIT IV
Section G.1
Comfort Management
Critical Elements for Comfort Management
1. Assesses comfort needs by
a.
Asking the patient to describe comfort needs
b.
OR
Observing behaviors indicative of discomfort
2. Provides THREE of the following comfort measures:
a.Assists the patient with washing face, hands, and/or vulnerable
skin surfaces
b.
Repositions the patient or assists the patient to a different position
c.
Gives the patient a backrub
d.
Uses relaxation and/or distraction techniques
e.
Applies heat or cold when assigned
f.
Assists the patient with mouth care
g.
Changes or adjusts bed linens
h.
Administers medication(s) when assigned
3. Records
a.
Data related to comfort needs or discomfort
b.
Comfort measures implemented
c.
Patient responses to measures implemented
Comfort Management is the assessment of comfort needs and the
implementation of measures to meet those needs. (Comfort Management
will not be assigned in the same PCS with Pain Management.)
Sometimes patients need a little extra attention and care to assist them with the
healing process. When comfort management is designated as part of your assignment
you assess comfort needs, and provide three comfort measures.
IV.G.1.b
1. Assesses comfort needs by
a.
Asking the patient to describe comfort needs
b.
OR
Observing behaviors indicative of discomfort
Assess your patient’s comfort needs, by asking the patient to describe his or her
comfort needs, or observing behaviors indicative of discomfort. Gather subjective
and objective data to assess comfort level (e.g., patient statements and body
language or family requests). Assess your patient based on developmental stage
and environmental constraints. Review the patient’s flow charts and nurse’s
notes to evaluate sleep patterns, hygiene needs, ability to provide self-care,
hobbies, distractions, and nutritional habits.
Patient comfort needs may be related to localized or general discomfort. An
example of localized discomfort is dryness of mouth or throat. Generalized
discomfort may be the result of fever, fatigue, itching, or lying in the same
position for an extended period of time. It is clear that providing mouth care
for the patient with pharyngitis or a dry oral cavity eases some discomfort.
An understanding of the cause of the patient’s discomfort obtained from your
assessment should serve as the foundation for you choice of measures to
implement to assist the patient to a state of comfort.
2. Provides THREE of the following comfort measures:
a.Assists the patient with washing face, hands, and/or
vulnerable skin surfaces
b.
c.
d.
e.
f.
Assists the patient with mouth care
g.
Changes or adjusts bed linens
h.
Administers medication(s) when assigned
After identifying the patient’s comfort needs and desires, decide which three
(3) comfort measures you will implement. Specific comfort measures such as
applying heat or cold and administering medications will be designated on
the PCS Assignment Kardex. Consider cultural implications if a patient starts
to deny discomfort. Be observant of other more subtle indications, i.e., facial
expressions, vital signs, diaphoresis, etc. Building a therapeutic relationship
with a patient is often necessary in order for the patient to trust you to provide
comfort measures.
Comfort Management
IV.G.1.c
Suggestions for Implementing Comfort Measures
• C
hanging the diaper of an infant is an example of assisting a patient with
washing a vulnerable skin surface. In addition to providing comfort, you
help the child maintain skin integrity.
• R
epositioning involves changing the patient’s position from one side to
another or from the bed to a chair. To promote comfort, devices such as
a sheepskin and egg crate pads may be used to reduce friction, while an
air mattress may be used to reduce pressure on skin surfaces. Holding an
infant is an age-appropriate method to reposition a baby.
• A
nother measure to promote comfort is mouth care. For a child under
4 years of age, the CE will designate the equipment to be used for
cleansing the mouth. Providing mouth care places the student at risk for
body fluid pathogen transmission; therefore, Standard Precautions must
be maintained.
• D
istracters such as involving a child in play, singing, changing position,
or listening to music may help the child to not focus on the discomfort
they are experiencing. Providing the infant/child with a pacifier, favorite
blanket, or toy may also promote comfort.
Examples of medications assigned to promote comfort include antiemetics,
emollients, topical medications for pain control, and throat sprays. When
medications are assigned as part of comfort management, the actual task of
giving the medication will be evaluated under the Area of Care, Medications.
When application of heat or cold is assigned, apply heat and/or cold therapy
according to basic principles, avoiding excessive temperatures and overexposure
of the site to treatment; e.g., aquathermia pads, ice packs.
1.Your patient is a 45-year-old man who experienced a traumatic injury to
his left arm following an industrial accident 24 hours ago. A very bulky
dressing covers his arm. He tells you he is nauseous. He has an intravenous
line with a continuous infusion of IV fluids in his right arm. What comfort
relief measures might be helpful for your patient?
_________________________________________________________________________
_________________________________________________________________________
IV.G.1.d
2.You are assigned an 86-year-old with arthritis, the CE has designated that
you apply the aqua K pad to the patient’s right arm for 20 minutes. Describe
how you plan to care for this patient’s comfort needs.
_________________________________________________________________________
_________________________________________________________________________
3.You are providing care for a 7-year-old child with hemophilia admitted for
dehydration and bleeding. She is receiving fluids, factor VIII concentrate,
pain meds and diet as tolerated. Your patient informs you that she is still
bruising easily, “ hurts all over” and describes her pain as a 4 on a faces
scale of 0–5.
What comfort measures would be beneficial for this child?
_________________________________________________________________________
_________________________________________________________________________
2. Records:
a.
Data related to comfort needs or discomfort
b.
Comfort measures implemented
c.
Patient response(s) to measures implemented
Record information you collected in the assessment of the patient’s comfort
needs, the three (3) comfort measures implemented, and the patient’s
response(s) to the measures implemented.
Required documentation would include your patient’s statement of being
comfortable or refusal of any comfort measures offered. Your documentation
should also include the three (3) comfort measures you provided as well as
the patient behavior prior to and post interventions. Document general patient
responses such as weakness, diaphoresis, if any, the duration of treatment, and
any discomfort or relief verbalized. If the patient does not offer information
regarding the effectiveness of the interventions, you will need to ask.
Example of an acceptable recording:
“Patient complains of pain in her lower back and says, “All I do is lie on my back
all day.” Back massaged with lotion, repositioned on left side after clean linen
applied. Patient states she feels much better.”
Example of an unacceptable recording:
“Washed hands and face. OOB to chair. Safety standards maintained.”
Comfort Management
IV.G.1.e
4.You have repositioned the patient, helped her wash her face and hands, and
offered to change the bed linen. The patient says, “I’m comfortable now and
the linen is fine.” What should you do?
_________________________________________________________________________
_________________________________________________________________________
5.You are assigned a 6-month-old admitted with sepsis, who has developed
a severe diaper rash. Perineal and perianal areas are extremely reddened
and excoriated, with several areas of small ulcerations. The infant screams
with each wet or soiled diaper. In addition to vital signs and abdominal
assessment, you are assigned comfort management.
a.
What should be included in your assessment?
_________________________________________________________________________
_________________________________________________________________________
b.
How would you involve the child’s parents in his care?
_________________________________________________________________________
_________________________________________________________________________
c.
What information would you record for this Area of Care?
_________________________________________________________________________
_________________________________________________________________________
Comfort Management
Your patient is a 45-year-old man who experienced a traumatic injury to his left arm
following an industrial accident 24 hours ago. A very bulky dressing covers his arm.
He tells you he is nauseous. He has an intravenous line with a continuous infusion
of IV fluids in his right arm.
1. What comfort measures might be helpful to your patient?
• Reposition his left arm: elevate left arm on pillows
• Offer backrub
• Offer mouth care
• Administer anti-emetic medication per order.
IV.G.1.f
2.You are assigned an 86-year-old patient with arthritis. According to your
assignment, the CE has designated that you apply the aqua K pad to the
patient’s right arm for 20 minutes. Describe how you plan to care for this
patient’s comfort needs.
Apply aqua K pad for 20 minutes. Instructed patient in guided imagery. Reposition
once discomfort is lessened.
3.You are providing care for a 7-year-old child with hemophilia admitted for
dehydration and bleeding. She is receiving fluids, factor 8 concentrate, pain
meds and diet as tolerated. Your patient informs you that she is still bruising
easily, “ hurts all over” and describes her pain as a 4 on the faces pain scale
of 0–5. What comfort measures would be beneficial for this child?
Repositioning, application of heat (if assigned), distraction activities such as telling
a story, singing songs with patient, administration of pain medication, if assigned.
4. You have repositioned the patent, helped her wash her face and hands and
offered to change the bed linen. The patient says, “ I’m comfortable now and the
linen is fine.” What should you do?
You provided 2 comfort measures and offered a third which the patient refused.
You have met the Critical Elements. Document this information in the narrative notes
section of the PCS Recording Form.
5. You are assigned a 6-month-old infant admitted with sepsis, who has developed
a severe diaper rash. Perineal and perianal areas are extremely reddened and
excoriated, with several areas of small ulcerations. The infant screams with each
wet or soiled diaper. In addition to vital signs and abdominal assessment, you
are assigned comfort management.
a.
What should be included in your assessment of the infant’s comfort needs?
Level of discomfort, cause of discomfort
How would you involve the child’s parents in his care?
b.
Applying skin product for diaper rash, soothing and comforting child after
diaper change.
c.
What information would you record for this Area of Care?
A description of the level and type of discomfort, comfort measures
implemented, the child’s response to the comfort measures.
IV.G.2.a
UNIT IV
Section G.2
Critical Elements for Musculoskeletal Management
1. Assesses the affected area of designated extremity(ies) for:
a.
Presence or absence of abnormalities (e.g., atrophy)
b.
Level of mobility
c.
Pain with movement
2. Directs the patient to move the joints of the designated extremity(ies)
through active range of motion by including at least one pair of the
following: abduction and adduction or flexion and extension
OR
3. Performs passive range of motion by
a.Moving the joints of the designated extremity(ies) through range of
motion at least once by including at least one pair of the following:
abduction and adduction or flexion and extension
b.Supporting the weight of the extremity(ies) at joints during range of
motion
4. Applies supportive or therapeutic devices to the designated body part(s)
5. Applies heat or cold when assigned by
a.
Protecting the skin surface of the body part to be treated
b.
Applying treatment to the designated body part
c.Applying treatment at the designated temperature (approximate)
d.Maintaining treatment for at least 20 minutes unless
otherwise designated
6. Maintains prescribed traction by
a.
Verifying the prescribed traction weight
b.
Assuring that ropes are unobstructed
c.
Assuring that weights hang freely
d.
Positioning the patient to provide countertraction
e.
Maintaining the patient in correct alignment
IV.G.2.b
7. Records
a.
Data related to
1)Presence or absence of abnormalities (e.g., atrophy) of the
designated extremity(ies)
2)
Level of mobility of the designated extremity(ies)
3)
Pain with movement in the designated extremity(ies)
b.
Musculoskeletal measures implemented
c.
The assessment for appearance, level of mobility and pain with movement
for the designated extremity (ies), and the encouragement of, or assistance
with, designated exercise(s) and supportive devices for therapeutic
purposes. Activities may include immobilization of one or more extremities
by continuous or intermittent traction to maintain body alignment, or
the application of wet or dry heat or cold to a body part for therapeutic
purposes. The patient may have splints or other therapeutic devices,
require range of motion, or be at risk for musculoskeletal deterioration
(e.g., bedrest).
Apply principles related to the hazards of immobility and provide care for a patient
who may be experiencing conditions that could lead to those hazards. The CE will
designate on the PCS Assignment Kardex the exercise(s) or supportive device(s) to
be applied and/or treatments to be maintained. When performing assessments,
perform on the assigned extremity(ies) only.
1. For the following patients with these medical diagnoses, identify the potential
hazards of immobility that a nurse providing musculoskeletal management
might prevent. What assessments or interventions are needed?
Patient has a medical
condition of
Hazards
of Immobility
Nursing Care Within
S/P knee replacement (TKR)
Diabetes
Post CVA with
unilateral paralysis
Post fall fractured femur
IV.G.2.c
a.
Presence or absence of abnormalities (e.g., atrophy)
b.
Level of mobility
c.
Pain with movement
The CE will assign the extremity(ies) on the PCS Assignment Kardex. Based
on the patient’s needs, upper or lower extremity(ies), or both upper and lower
extremities may be designated. Note the presence of or absence of abnormalities
such as atrophy or contractures. Assess level of mobility by noting if patient is
on bedrest, able to reposition self, get out of bed or walk independently and if
not, how much assistance is required. Assess if patient has pain with movement
by noting nonverbal expressions of discomfort or asking the patient about pain
when repositioning, getting out of bed, ambulating or performing range of
motion exercises.
2. Directs the patient to move the joints of the designated extremity(ies)
through active range of motion by including at least one pair of
the following: abduction and adduction, or flexion and extension
OR
a.Moving the joints of the designated extremity(ies) through range
of motion at least once by including at least one pair of the
following: abduction and adduction or flexion and extension
b.Supporting the weight of the extremity(ies) at joints during range
of motion
You will be assigned active or passive range of motion (ROM) of upper, lower,
or both extremities. When ROM is designated you will be expected to direct or
assist the patient to perform at least one pair of the following movements:
abduction and adduction
flexion and extension
All joints of the designated extremity(ies) are assessed. When doing passive
range of motion exercises assist the patient to perform joint movement
smoothly, slowly, and rhythmically while supporting the joint. Uneven, jerky
movement and forcing can injure the joint and it’s surrounding muscles and
ligaments.
You should practice range of motion exercises under the supervision of a
professional nurse or physical therapist, using the Critical Elements as a guide
for evaluation of your performance.
IV.G.2.d
When designated on the PCS Assignment Kardex, you are to apply supportive
or therapeutic devices to the designated body parts. Orientation to equipment
used during the PCS will be conducted during the unit orientation or at the
bedside. Be familiar with the principles underlying the use of supportive or
therapeutic devices to be able to manage the patient’s safety during the use of
such equipment.
Examples of therapeutic devices which might be included in a patient’s
therapeutic regimen are as follows:
Continuous passive range of motion machines (CPM)
Splints/braces
Antiembolism support stockings
Immobilizers
Sequential compression stockings
a.
Protecting the skin surface of the body part to be treated
b.
Applying treatment to the designated body part
c.
Applying treatment at the designated temperature (approximate)
d.Maintaining treatment for at least 20 minutes unless
To be successful with the application of heat or cold, protect the skin surface of
the body part to be treated, and apply the correct treatment to the designated
body part at the correct temperature for at least 20 minutes. The safe use of heat
or cold requires prior assessment of the patient’s sensory function, identification
of risk factors, and understanding of the physiological effect of heat and cold.
Remember that while this intervention assists in maintaining musculoskeletal
function, it may also be used for comfort management and pain management.
IV.G.2.e
2.You are providing care to an 85-year-old female S/P total knee replacement
(TKR). She has the original surgical dressing on with an external
immobilizer. Your assignment is to ambulate the patient to the bathroom,
apply ice packs, and complete musculoskeletal management in addition to
obtaining vital signs and performing fluid management.
a.What risk factors, if any does this patient have for injury related to
cold application?
_________________________________________________________________________
_________________________________________________________________________
b.List below the steps you could take to complete the patient’s care
related to the application of heat and cold. What Critical Elements
would you be implementing? List the steps in priority order.
Patient Care Activities
Prioritization
IV.G.2.f
a.
Verifying the prescribed traction weight
b.
Assuring that ropes are unobstructed
c.
Assuring that weights hang freely
d.
Positioning the patient to provide counter traction
e.
Maintaining the patient in correct alignment
If traction is assigned for Musculoskeletal Management, you are to maintain the
traction by verifying the prescribed traction weight and assuring that ropes are
unobstructed, weights hang freely, and the patient remains positioned correctly
for countertraction and alignment. You should check the patient early in the
PCS and periodically throughout the PCS to determine that traction is being
maintained. You would not be expected to set up or initiate traction.
3.Your patient is a 13-year-old who was admitted with fractured tibia and
fibula. She has been placed in skeletal traction. Your assignment includes
Vital Signs, Fluid Management, Musculoskeletal Management with traction
designated, Patient teaching coassigned with Musculoskeletal Management,
and Comfort Management.
a.Write two nursing diagnostic statements related to the assigned Areas
of Care for this Patient Care Situation. Include possible related factors
and defining characteristics based on your knowledge about children
orthopedics, and traction.
_________________________________________________________________________
_________________________________________________________________________
b.For one of the above diagnoses, write one measurable outcome
for this type of patient.
_________________________________________________________________________
_________________________________________________________________________
c.What are two interventions that you could carry out during the
Patient Care Situation that would assist the patient in achieving the
stated outcome?
_________________________________________________________________________
_________________________________________________________________________
IV.G.2.g
d.What information would you need to collect during the
Implementation Phase to adequately evaluate the patient’s
progress toward achievement of the outcome and the
effectiveness of your interventions?
_________________________________________________________________________
_________________________________________________________________________
7. Records
a.
Data related to
1)Presence or absence of abnormalities (e.g., atrophy) of the
designated extremity(ies).
2)
Level of mobility of the designated extremity(ies).
3)
Pain with movement in the designated extremity(ies).
b.
Musculoskeletal measures implemented
c.
Documentation of assessment findings, measures implemented and patient
response is completed in the narrative notes section of the Student PCS
Recording Form.
Example of an Acceptable Recording:
“Active ROM, right side moves easily with full range of motion to wrist, elbow,
shoulder, hip, knee, and ankle joints. Passive ROM to left side, wrist, and elbowcontracted in flexed position, shoulder fixed. Plantar flexion of left ankle, flexion
contractures on hip and knee. Body alignment maintained by use of pillows,
repositioned x1 to right side. Patient tolerated activity with no shortness of
breath, diaphoresis, or fatigue noted.”
IV.G.2.h
1. For the following patients with these medical diagnoses, identify the potential
hazards of immobility that a nurse providing Musculoskeletal Management might
prevent. What assessments or interventions are needed?
Patient has a medical
condition of
S/P knee replacement (TKR)
Hazards
of Immobility
Decreased ROM, contractures, blood clots, pulmonary
emboli, pressure ulcer
Nursing Care Within
• Direct patient to perform
AROM of unaffected
joints total
• Maintain CPM per order
• Reposition patient
• Provide skin care to
bony prominences
Diabetes
Post CVA with
unilateral paralysis
Skin breakdown
• Provide skin care
Poor perfusion of lower
extremities
• Ambulate patient
Skin breakdown
• Reposition frequently
Contractures
• Provide skin care
• Encourage AROM to
unaffected extremities
• Provide PROM to
affected extremity
Post fall fractured femur
Skin breakdown
• Maintain traction per order
Blood clots
• Reposition patient using
trapeze bar
• Encourage AROM to
unaffected joints
2. You are providing care to an 85-year-old female status post total knee
replacement (TKR). She has the original surgical dressing on with an external
immobilizer. Your assignment is to ambulate the patient to the bathroom, apply
ice packs and complete Musculoskeletal Management in addition to Vital Signs
and performing Fluid Management.
IV.G.2.i
a.What risk factors, if any, does this patient have for injury related to cold
application?
Cold applications cause vasoconstriction resulting in possible decrease in tissue
perfusion. When cold is applied, the skin should be protected from blanching
resulting in tissue damage. A barrier should be placed between the cold pack
and the skin. In this case the dressing would act as a barrier. Apply the ice
pack for approximately 20 minutes or per order. Leaving the cold application
on too long produces the opposite effect.
List below the steps you could take to complete the patient’s care related to the
application of heat or cold.
b.What Critical Elements would you be implementing? (list the steps in
priority order)
Patient Care Activities
Apply ice pack
Prioritization
• Explain the treatment to the patient
• Protect the skin surface of the body part to
be treated
• Use the prescribed treatment/solution
• Apply treatment at the designated temperature
• Apply treatment to designated body part
• Maintain treatment for at least 20 minutes
unless otherwise designated
• Record the patient’s response
3. Your patient is a 13-year-old who was admitted with a fractured tibia and fibula.
She has been placed in a skeletal traction. Your assignment includes Vital Signs,
Fluid Management, Musculoskeletal Management with traction designated,
Patient Teaching co-assigned with Musculoskeletal Management and Comfort
Management
a.Write two nursing diagnostic statements related to the assigned Areas
of Care for this patient. Include possible related factors and defining
characteristics based on your knowledge about children, orthopedics
and traction.
• Impaired physical mobility related to musculoskeletal impairment.
• Acute pain related to tissue trauma
IV.G.2.j
b.For one of the above diagnoses, write one measurable outcome for this
type of patient.
Impaired physical mobility: Patient will express feeling of increased strength.
c.What are two interventions you could implement during the Patient Care
Situation that would assist the patient to achieve the outcome stated?
1.Have patient demonstrate active ROM exercises to unaffected extremities.
2.
Ensure the traction forces are maintained during exercises.
d.What information would you need to collect during the Implementation
Phase to adequately evaluate the patient’s progress toward the achievement
of the outcome and the effectiveness of your interventions?
Observe the patient’s ability to do the exercise as prescribed. Observe patient’s
response to increased activity.
IV.G.3.a
UNIT IV
Section G.3
Oxygen Management
Critical Elements for Oxygen Management
1. Assesses the patient’s response to activity
2. Assesses oxygenation status by
a.
Inspecting nailbeds for color, capillary refill, or clubbing
b.
OR
Measuring oxygen saturation level when assigned
3. Assesses skin surfaces in contact with oxygen delivery system
4. Positions the patient to facilitate respiration
5. Sets, adjusts, or maintains oxygen flow at designated rate
(liters or percent)
6. Maintains humidification of oxygen if humidification is present
7. Removes articles, if present, which can produce a spark or flame
from bedside area
8. Applies, inserts, or maintains device to deliver oxygen at the
designated rate when required
9. Applies and maintains instrument to measure oxygen saturation level,
when assigned
10.Records
a.
Data related to
1)
Response to activity level
2)
Oxygenation status
3)Condition of skin surfaces in contact with
oxygen delivery system
b.
Oxygenation management measures implemented
c.
Patient response to measures implemented
IV.G.3.b
Oxygen Management is the assessment of oxygenation status, the
administration of oxygen or compressed air by cannula, mask, croupette,
or other devices, and the measurement of oxygen saturation when assigned.
(Oxygen Saturation, if assigned in Oxygen Management, will not be assigned
in the same PCS in either Vital Signs or Respiratory Assessment.)
The CE will designate the amount and method of oxygen delivery on the PCS
Assignment Kardex. Oxygen flow rate may be designated in liters (e.g., 3L/min) or
by the percentage of oxygen in the air (e.g., 40%). When assigned, measure oxygen
saturation. For all Patient Care Situations where Oxygen Management is assigned,
assess the patient’s oxygenation status and response to activity. While managing
oxygen, position the patient to facilitate respiration, deliver oxygen at the designated
rate, maintain humidification of oxygen if humidification is present, and keep the
environment free of hazards which might accelerate a fire.
You may be assigned to provide nursing care using various kinds of respiratory
therapy equipment such as mist tents, croupettes, nebulizer treatments, or devices to
measure oxygen saturation. You are responsible for ensuring that any equipment used
to provide patient care within the assigned Area of Care is functioning properly during
the PCS. You will not be expected to care for patients on ventilators.
1. Identify the types of patients who might require Oxygen Management. For each
type of patient identified, write a possible nursing diagnostic label for a potential
or actual patient problem related to oxygen management.
______________________________________________________________________________
______________________________________________________________________________
2. What conclusions can you draw from comparing these diagnostic labels?
______________________________________________________________________________
______________________________________________________________________________
3. For one patient, create a nursing diagnosis with possible contributing factor
and defining characteristics for an actual patient problem.
______________________________________________________________________________
______________________________________________________________________________
4. Write one measurable outcome for that diagnosis.
______________________________________________________________________________
______________________________________________________________________________
5. Write two interventions that you could implement during a Patient Care Situation.
______________________________________________________________________________
______________________________________________________________________________
Oxygen Management
IV.G.3.c
6. What information would you need to collect during the Implementation Phase to
adequately evaluate your patient’s progress toward achievement of the outcome
and effectiveness of your interventions?
______________________________________________________________________________
______________________________________________________________________________
1. Assesses the patient’s response to activity
2. Assesses oxygenation status by
a.
Inspecting nailbeds for color, capillary refill, or clubbing
b.
OR
Measuring oxygen saturation level, when assigned
Assessment of your patient’s response to activity and oxygenation status is an
important skill within this Area of Care. Assessment of response to activity can
be made by observing the patient for shortness of breath or dyspnea on exertion
after repositioning, ambulating, or participating in activities. You also may
observe the patient for changes in vital signs (i.e., pulse and/or respiratory rate)
after activity.
To assess oxygenation status during the CPNE, you should either observe the
appearance of your patient’s nailbeds or measure oxygen saturation when
assigned. If O2 saturation is not assigned, assess and record the appearance of
the patient’s nailbeds. Assess nailbeds for color, capillary refill, or clubbing. If O2
saturation is assigned measure oxygen saturation and record the measurement
in the narrative note. A transcutaneous oximeter is one type of equipment that
is used to measure the oxygen saturation level. You will be oriented to the
equipment used in the test site facility for measuring oxygen saturation. If you
are assigned to report oxygen saturation level within certain parameters, these
parameters for reporting will be indicated on the PCS Assignment Kardex (e.g.,
report O2 sat< 92%).
3. Assesses skin surfaces in contact with oxygen delivery system
Assess skin surfaces in contact with the oxygen delivery system and report
abnormal findings such as redness or irritation.
4. Positions the patient to facilitate respiration
5. Sets, adjusts, or maintains oxygen flow at designated rate
(liters or percent)
IV.G.3.d
6. Maintains humidification of oxygen if humidification is provided
7. Removes articles, if present, which can produce a spark or flame from
bedside area
8. Applies, inserts, or maintains device to deliver oxygen at the designated
rate when required
9. Applies and maintains instrument to measure oxygen saturation level
when assigned
7.Your patient’s O2 saturation level is 89% on room air. Write a NCP for
this patient.
_________________________________________________________________________
_________________________________________________________________________
While managing the delivery of oxygen, position your patient to promote
respiration, deliver O2 at the designated rate through the designated device,
and remove articles which could produce a spark or flame from the bedside
area. When oxygen delivery is humidified, maintain the humidification by
refilling or adding to the humidification chamber if the water falls below
the refill line. If the patient does not have humidification ordered, you are
not required to provide humidification. You may need to adjust the flow
rate of oxygen based on the oxygen saturation reading and the oxygen
titration protocol, indicated on your PCS assignment Kardex.
10.Records
a.
Data related to
1)
Response to activity level
2)
Oxygenation status
3)Condition of skin surfaces in contact with oxygen
delivery system
b.
Oxygenation management measures implemented
c.
Document data collected about oxygenation status, condition of skin surfaces,
oxygen management measures implemented, your patient’s response to
activity level, and your patient’s response to the interventions implemented
for successful completion of the Area of Care Oxygen Management. Document
the method of delivery, flow rate of O2 (or O2% of concentration), and the
patient’s response to the oxygen device used for oxygen management measures
Oxygen Management
IV.G.3.e
implemented. Patient response documentation includes data about the
improvement or deterioration of the patient’s condition in response to
oxygen therapy.
“O2 maintained at 2L via nasal cannula. Skin of left nare intact, right nare
reddened. Patient respirations remain unlabored, nailbeds pink. O2 saturation
level at 97% with oxygen flowing. Able to transfer to chair without shortness
of breath.”
“Patient respiratory rate is 16, unlabored breathing pattern and regular rate when
O2 flow maintained at 40% via face mask. Skin is intact around face mask and
elastic strap. Capillary refill less than 3 seconds. Able to ambulate to door with
portable O2 tank without shortness of breath.”
8.For the following documentation examples, determine whether Critical
Elements for documentation have been met. If not, rewrite documentation
so it meets the Critical Elements.
Critical Elements Met?
(yes/no)
Corrected Documentation
(to meet Critical Elements)
Tolerated activity. No shortness
of breath noted; oxygen
saturation 94%: Skin behind
ears and nares intact. States
he is comfortable.
Became short of breath when
head of bed lowered from 90º
to 45º. O2 maintained.
IV.G.3.f
Oxygen Management
1. Identify types of patients who might require Oxygen Management. For each type
of patient identified, write a possible nursing diagnostic label for a potential or
actual problem related to Oxygen Management.
• Pneumonia: Ineffective airway clearance
• Congestive Heart Failure: Activity intolerance
• Peripheral Vascular Disease: Altered tissue perfusion
2. What conclusions can you draw from comparing these diagnostic statements?
There are several body systems that are affected by an interference in oxygenation.
3. For one patient, create a nursing diagnosis with possible contributing factors and
defining characteristics for an actual patient problem.
Activity Intolerance related to decreased cardiac output, as evidenced by dyspnea on
exertion and fatigue
4. Write one measurable outcome for that diagnosis.
Patient will be able to perform ADLs without becoming short of breath.
5. Write two nursing interventions that you could implement during a
Patient Care Situation
1.
Place articles needed for ADLs within patient’s reach.
2.
Provide frequent rest periods during ADLs.
6. What information would you need to collect during the Implementation Phase
to adequately evaluate your patient’s progress toward the achievement of the
outcome and effectiveness of your interventions?
Did his respiratory rate increase during activity and did it return to baseline at rest?
Was the patient short of breath? Was the patient able to perform ADLs?
Oxygen Management
IV.G.3.g
7. Your patient’s O2 saturation level reads 89% on room air. Write a NCP
for this patient.
Risk for impaired gas exchange
r/t ventilation and perfusion imbalance
Outcome: Patient will remain free from signs of respiratory distress,
such as tachypnea, SOB, diaphoresis.
Intervention:
1. Monitor O2 saturation in room air.
2. Position patient for optimal respiratory effect.
8. For the following documentation examples determine whether Critical Elements
for documentation have been met. If not, rewrite the documentation to meet the
Critical Elements criteria.
Critical Elements Met?
(yes/no)
Corrected Documentation
(to meet Critical Elements)
Tolerated activity. No shortness
of breath noted; oxygen
saturation 94%: Skin behind
ears and nares intact. States
he is comfortable.
Yes
N/A
Became short of breath when
head of bed lowered from 90º
to 45º. O2 maintained.
No
Oxygen saturation 90%
maintained HOB at 90
degrees. Primary nurse
notified.
Note does not describe if
HOB returned to 90 degrees.
Also, “O2 maintained” suggests that patient is on
oxygen therapy rather than
describing the oxygen saturation level. Also if the patient
is on oxygen the response
does not specify amount of
O2 being administered.
IV.G.3.h
IV.G.4.a
UNIT IV
Section G.4
Pain Management
Critical Elements for Pain Management
1. Assesses the patient’s level of pain by
a.
sking an adult patient to rate level of pain using a 0-10 scale
A
OR
c.Using the FLACC pain assessment tool to rate level of pain
OR
b.Asking a child to rate level of pain using a 0-5 faces scale or
age-appropriate visual analog scale
OR
2. Administers pain medication(s), when assigned
OR
3. Reports the patient’s level of pain to the assigned staff nurse
4. Provides one of the following pain relief measures:
a.
b.
c.
d.
5. Reassesses level of pain by
a.Asking an adult patient to rate level of pain using a 0–10 scale
b.Asking a child to rate level of pain using a 0–5 faces scale or
OR
OR
OR
IV.G.4.b
6. Records
a.
Patient’s level of pain
b.
Pain relief measures implemented
c.
Pain Management is the assessment of the presence of pain and the
implementation of pain relief measures. (Pain Management will not be
assigned in the same PCS with Comfort Management. If Pain Management
is assigned in a PCS, Pain Level will not be assigned in the Area of Care
Vital Signs.)
Assess the patient’s level of pain, provide pain relief measures, administer pain
medication when assigned, and reassess the patient’s level of pain after pain relief
measures are provided. Assessing and identifying the factors contributing to the
patient’s pain will help you to determine appropriate pain relief measures. Having a
comprehensive knowledge of theories/concepts of pain management will assist you
in providing effective interventions.
1. Assess level of pain by:
a.
sking an adult patient to rate level of pain using a 0-10 scale
A
b.Asking a child to rate level of pain using a 0-5 faces scale or
OR
OR
OR
Assess your patient’s level of pain, using an appropriate rating scale. If a patient
is unable to rate his or her pain using a pain scale, then observe and record
behaviors indicative of pain. These are the same scales to be used if assessing a
patient’s level of pain within the Area of Care Vital Signs. If you are not assigned
Pain Management as a Selected Area of Care, pain assessment will be assigned
as part of Vital Signs. Determining information about the location, duration,
intensity, and severity of the pain, as well as the aggravating and relieving
factors, will assist you in selecting the most effective pain relief measures.
Pain Management
IV.G.4.c
2. Administers pain medication(s), when assigned
OR
3. Reports the patient’s level of pain to the assigned staff nurse
Implement pain management strategies after assessing a patient’s level of pain.
If Medications are assigned, the medications assigned will be written under
the Area of Care Medications on the PCS Assignment Kardex. Review the pain
medication ordered and administer as prescribed after assessing the patient’s
level of pain.
If the CE does not assign administration of pain medications, report the patient’s
level of pain to the assigned staff nurse. The time frame within which you report
the patient’s level of pain is directly related to the amount of pain that the patient
is experiencing.
1.Your patient is experiencing increasing abdominal pain and has vomited.
Medication for pain has been ordered to be given either by PO or IM route.
Which route should you use?
_________________________________________________________________________
_________________________________________________________________________
4. Provides one of the following pain relief measures
a.
b.
c.
d.
When pain relief measures is designated on the PCS Assignment Kardex, provide
one measure such as repositioning, backrub, massage, or guided imagery and/
or distraction techniques. If application of heat or cold is assigned, the CE will
write specific orders for the modality to be used. Pediatric specific pain relief
measures would include, but not be limited to, the use of a pacifier, cuddling,
and distraction with play, singing, and/or a favorite toy.
When providing a pain relief measure, consider age, culture, and gender specific
implications. Check the patient’s MAR to determine the pain medications the
patient is receiving and when the last dose was given. When possible explore
first with the patient what non-pharmacological interventions have been used
previously and, if so what has been successful and what has not worked or has
been uncomfortable for the patient.
IV.G.4.d
Implement at least one pain relief measure in addition to:
• Pain medication administration (assigned in Pain Management) or,
• A
pplication of heat or cold when assigned in Musculoskeletal
Management
5. Reassesses level of pain by
a.Asking an adult patient to rate level of pain using a 0–10 scale
OR
OR
b.Asking a child to rate level of pain using a 0–5 faces scale or
OR
Reassess the patient’s level of pain after the interventions have been implemented. Standard of care is that you reassess the patient’s level of pain within
30 minutes of pain medication administration and /or after relief measures are
implemented. Determine the patient’s response to the intervention by comparing
the patient’s level of pain before and after the pain relief measures were implemented. Use the same pain rating scale used for your initial pain assessment.
2.
What does “pain is what the patient says it is” mean?
_________________________________________________________________________
_________________________________________________________________________
3.Why is it appropriate to use more than one means of achieving pain relief?
_________________________________________________________________________
_________________________________________________________________________
4.When and how should the effectiveness of the pain relief measure
be evaluated?
_________________________________________________________________________
_________________________________________________________________________
Pain Management
IV.G.4.e
6. Records:
a. Patient’s level of pain
b.
Pain relief measures implemented
c.
Record information you collected about the patient’s level of pain, pain
relief measures implemented, and the patient’s response(s) to the measures
implemented in a narrative note on the PCS Response Form. Required
documentation includes the patient rating of pain unless the patient is unable
to rate his or her own pain. Then patient behaviors reflecting presence or
absence of pain would be expected.
An example of acceptable recording:
Patient complained of sharp right hip incision pain, radiating down her right leg,
and rated pain level at 4 on scale of 0–10. Patient repositioned and back rub
given. Patient continued to rate pain as 4 after repositioning and backrub. Level
of pain reported to assigned staff nurse who medicated the patient with 2 tablets
of Tylenol #3 at 0915. Thirty minutes after taking the Tylenol #3 the patient rated
level of pain as 1 on a scale of 0–10.
5.Evaluate the following notes using the recording Critical Elements as a
guide. Rewrite the notes that do not meet the requirements of the CPNE.
Example of
documentation
Meets expectations
Yes/No
What is missing?
Note rewritten to
standards set in
Critical Elements
Remains in bed
guarding abdomen,
knees curled to chest.
Repositioned on left
side. Back rub given.
Patient lying quietly
with eyes closed.
Reported to primary
care nurse.
Pain level 3. Medicated
per orders. Patient
sleeping now.
Patient identifies
pain as 4 on faces
pain scale. Pain level
reported to staff.
IV.G.4.f
Example of
documentation
Meets expectations
Yes/No
What is missing?
Note rewritten to
standards set in
Critical Elements
Complains of sharp
incisional pain in right
knee. Ice pack applied.
Patient states it feels
good.
Parents describe
their toddler as being
restless, irritable,
and unable to be
comforted. You
observe the child to be
crying loudly, unable
to be comforted. Pain
medication given,
and parents now
holding child who is
occasionally sobbing
but no longer crying
or screaming.
Eight year old patient
on bedrest, c/o pain of
5, left leg in traction.
TV turned on, and
patient now resting
comfortably
Pain Management
Your patient is experiencing abdominal pain and has vomited. Medication for pain has
been ordered to be given either PO or IM route.
1. Which route should you use?
The patient has vomited therefore the IM route would be appropriate.
2. What does “pain is what the patient says it is” mean?
Perception of pain is an individual’s reality. The response is physiological, behavioral
and emotional, therefore it is impossible to know what the person is feeling. If a
patient says they have a pain level of 7 on a scale of 0–10 but does not appear to
be in pain, the pain must be treated.
Pain Management
IV.G.4.g
3. Why is it important to use more than one means of achieving pain relief?
When only one pain relief measure is used you may not obtain the desired result.
Pain relief measures tend to compliment one another and potentiate the patient’s
pain relief.
4. When and how should the effectiveness of the pain relief measure be evaluated?
Depending on what medication and route are used, you need to wait for twenty
to thirty minutes to evaluate the effect by asking the patient to rate his pain on
the pain scale. At the same time you would also evaluate the patient’s response to
repositioning, massage or whatever relief measures you provided for pain relief.
5. Evaluate the following notes using the recording Critical Elements as a guide.
Rewrite the notes that do not meet the requirements of the CPNE.
Example of
documentation
Meets expectations
Yes/No
What is missing?
Remains in bed
guarding abdomen,
knees curled to chest.
Patient lying quietly
with eyes closed.
Reported to primary
care nurse.
No
The patient’s
response to the pain
relief measures as
described by the pain
rating scale. Just
because the patient
is lying quietly does
not mean that he is
not in pain.
Pain level 3. Medicated
per orders. Patient
sleeping now.
No
Needs additional pain Patient rates pain
relief measure.
3/5. Following distraction with a game
and being medicated,
the patient is now
sleeping.
Patient identifies
pain as 4 on faces
pain scale. Pain level
reported to staff.
No
No pain relief
measures
documented
No reassessment
Note rewritten to
standards set in
Critical Elements
Pain level is a 7 on
the pain scale of
0 –10, remains in
bed, guarding abdomen with knees
curled to chest.
After 20 minutes,
patient states his
pain is now a 3 on
a 0 –10 scale.
Patient identifies pain
as 4 on pain faces
scale of 0 – 5. Pain
level reported to staff.
Patient repositioned
and medicated by
staff nurse. Patient
identified pain as a 1
on pain faces scale of
0 – 5 after 20 minutes.
IV.G.4.h
Example of
documentation
Meets expectations
Yes/No
Complains of sharp
incisional pain in right
knee. Ice pack applied.
Patient states it feels
good.
No
Parents describe
their toddler as being
restless, irritable,
and unable to be
comforted. You
observe the child to be
crying loudly, unable
to be comforted. Pain
medication given,
and parents now
holding child who is
occasionally sobbing
but no longer crying
or screaming.
Yes
Eight year old patient
on bedrest, c/o pain of
5, left leg in traction.
TV turned on, and
patient now resting
comfortably
No
What is missing?
Note rewritten to
standards set in
Critical Elements
Pain scale before and
after treatment
Pain is 4 on pain
scale of 0 –10. Pain
level after ice application is now 2.
Information about
when pain rating of
5 was obtained
(before or after pain
relief measures).
Pain rating after pain
relief measure(s)
implemented
Eight-year-old patient
on bedrest, c/o pain
of level 5 on a pain
faces scale of 0 – 5.
Left leg in traction.
TV turned on. After
watching TV for 20
minutes, pain level
reassessed, obtained
a level 2 on the
pain faces scale and
patient now lying
quietly in bed in
proper alignment;
smile when talked to
in a calm voice.
IV.G.5.a
UNIT IV
Section G.5
Critical Elements for Respiratory Management
2. Positions the patient to facilitate respiratory hygiene activity(ies)
3. Provides a receptacle to receive secretions as needed
4. Assesses the patient’s respiratory status before initiating respiratory
hygiene activity(ies) by
deeply as possible
c.
5. Directs the patient in or performs one or more respiratory
hygiene activity(ies)
Deep breathing:
1)Instructs the patient specifically to breathe in and out
as deeply as possible
2)Repeats deep breathing exercises as ordered or as indicated
by the patient’s condition
Coughing:
b.
1)Instructs the patient specifically to breathe in and out deeply
2)Instructs the patient specifically to cough forcefully on third
or fourth expiration
3)Provides for splinting while the patient is coughing if
necessary
a.
c.Mechanical devices such as those used for inspiratory
spirometry, etc:
1)
Instructs the patient specifically to use the device
2)Repeats respiratory exercise as ordered or as indicated
IV.G.5.b
d.
Chest Percussion:
1)Claps the designated area(s) of the chest wall vigorously
with cupped hands unless contraindicated
2)Vibrates the designated area(s) of the chest wall vigorously
Suctioning:
e.
1)
When suctioning by catheter is assigned:
a)
Verifies patency of the catheter
b)
Sets the pressure on the suction machine as designated
c)
Inserts the catheter before suctioning
d)
Rotates the catheter continuously during suctioning
e)
Suctions for no more than 15 seconds at a time
f)
Repeats as necessary to remove secretions
2)
OR
When suctioning by bulb syringe is assigned:
a)
Deflates the bulb syringe prior to insertion
b)Inserts the bulb syringe into the patient’s mouth
and/or nares before suctioning
c)
Aspirates secretions
d)
6. Reassesses respiratory status immediately after respiratory
hygiene activities.
7. Records
a.Bilateral breath sounds heard after treatment in comparison
with those heard initially, related to each of the above
assessment findings
b.
c.
Respiratory hygiene activities implemented
d.
Patient response to hygiene activities implemented
Respiratory Management is the assessment of respiratory status and the
encouragement of, instruction about, assistance with, and determination
of the effectiveness of respiratory hygiene activities. Respiratory hygiene
activities include deep breathing, coughing, chest percussion, suctioning,
and/or the use of mechanical devices. (Respiratory Management will not
be assigned in the same PCS with Respiratory Assessment.)
IV.G.5.c
You may be assigned one or more respiratory hygiene activities as part of
Respiratory Management. Respiratory hygiene activities may include deep
breathing, coughing, chest percussion, suctioning, and the use of mechanical
devices.
2. Positions the patient to facilitate respiratory hygiene activity(ies)
Auscultate the patient’s breath sounds while the patient is in an upright position
unless this position is contraindicated. For patients who are unable to sit upright
but can turn, the side lying position is acceptable
3. Provides a receptacle to receive secretions as needed
A receptacle to receive secretions may include an emesis basin and/or tissues.
Wear gloves if your patient has a productive cough and is expectorating sputum.
Remember that Standard Precautions are in effect at all times during the CPNE.
4. Assesses the patient’s respiratory status before initiating respiratory
hygiene activity(ies) by
deeply as possible
You may auscultate either the anterior or posterior chest. We recommend
listening to breath sounds over the posterior chest because you will hear
them more clearly over the posterior chest. The following diagrams represent
the anterior and posterior lung surfaces. Compare the lung fields by moving
the stethoscope systematically from side to side. Auscultation over a bony
prominence or a nonlung field will constitute a failure of the PCS. Perform an
assessment of the lungs according to stated Critical Elements before and after
all respiratory hygiene treatments are completed. When assessing the lungs,
observe any side effects of the deep breathing; e.g., lightheadedness or dizziness.
You should be able to discriminate between normal and abnormal sounds.
IV.G.5.d
c.
Before beginning any respiratory hygiene activities, establish a base line
assessment by observing breathing patterns while the patient breathes in
and out as deeply as possible.
1.As you describe the Respiratory Management activities you are about
to implement, the patient reaches for and attempts to start Incentive
Spirometry (IS). What should you do to ensure that your baseline
assessment of breath sounds is completed prior to the initiation of
respiratory hygiene activities?
_________________________________________________________________________
_________________________________________________________________________
2.If the patient implements IS prior to your cue to enter the Area of Care,
what should you do?
_________________________________________________________________________
_________________________________________________________________________
IV.G.5.e
5. Directs the patient in or performs one or more respiratory
hygiene activity(ies):
a.
Deep Breathing:
1)Instructs the patient specifically to breathe in and out as
deeply as possible
2)Repeats deep breathing exercise as ordered or as indicated
Coughing:
b.
1)
Instructs the patient specifically to breathe in and out deeply
2)Instructs the patient specifically to cough forcefully on
third and fourth expiration
3)Provides for splinting while the patient is coughing
if necessary
After completing your assessment of breath sounds and observing your patient’s
breathing pattern, immediately direct the patient in the assigned respiratory
hygiene activities. For deep breathing, specifically instruct the patient to breathe
in and out as deeply as possible and to repeat the deep breathing exercises
the number of times assigned or as indicated by your patient’s condition. If the
patient has not breathed deeply or coughed effectively, repeat the deep breathing
and coughing exercises after you repeat your instructions for deep breathing
and coughing. Evaluate the patient’s coughing because spontaneous coughing
is often not effective in aerating the lungs. Splinting can be provided by using a
pillow or bath blanket or by instructing your patient to use his or her hands.
Case Study
If your patient spontaneously coughed before you instructed him or her
to deep breathe, you will need to decide whether the cough alone was
effective. If you decide that the cough was effective, inform the CE that
you are omitting deep breathing and provide your rationale verbally at
that time.
IV.G.5.f
Critical Thinking/Applications to Practice
3.You are caring for a patient who is less than 24 hours s/p open
cholecystectomy. The patient is quiet, moving slowly in bed. You are
assigned Respiratory Management with deep breathing and coughing.
For the following examples of CDM, evaluate the nursing actions and
score the behaviors as pass/fail for CDM. Write a rationale for your choice.
Nursing Actions
Pass/Fail
Rationale
Verbalize that you will omit
coughing because your patient
looks uncomfortable.
Assist the patient to a sidelying position, provide a
back rub, auscultate lungs,
assist the patient to a sitting
position, instruct the patient to
breathe and cough, auscultate
lungs, assist the patient to a
comfortable position.
Auscultate lungs. Patient
complains that, “it hurts.”
Verbalize that you will defer
deep breathing and coughing
and that you will go to the
primary nurse and request
that the patient be medicated
for pain. One half hour after
patient is medicated, auscultate
lungs, five repetitions deep
breathing. Auscultate lungs.
c.Mechanical devices, such as those used for inspiratory
spirometry, etc.:
1)Instructs the patient specifically to use the device
If the use of a mechanical device to promote respiratory function is assigned,
the CE will designate the device to be used and the number of repetitions. Be
familiar with mechanical devices used to promote respiratory function. The CE
will orient you to the hospital-specific equipment during the unit orientation or
once in the patient’s room. Assisting the patient in using the device for optimal
lung aeration is an important aspect of this Critical Element.
d.
IV.G.5.g
Chest Percussion:
1)Claps the designated area(s) of the chest wall vigorously
with cupped hands unless contraindicated
When chest percussion is assigned on the PCS Assignment Kardex clap over
designated area(s) of the chest wall vigorously with cupped hands unless
contraindicated. Your clapping of the chest wall with your cupped hands should
be firm enough to loosen secretions. The size of the adult or child patient should
determine the force of your percussion and the exact method you use.
For a child under 1 year of age, the CE will designate the instrument to be used
for clapping; i.e., hands, fingers, or other device. If the patient is required to be in
a particular position during the percussion, the CE will write this information on
the PCS Assignment Kardex.
Students who lack experience with this skill often clap too lightly or do not
position the patient correctly. Generally, if the sound made by cupping/clapping
can be heard several feet away, percussion will be effective. The sound has been
described as like that made by a galloping horse. Vibration or shaking with flat
hands is often preformed in conjunction with clapping to loosen secretions and
propel them into the larger bronchi.
e.
Suctioning:
1) When suctioning by catheter is assigned:
a)
Verifies patency of the catheter
b)
Sets the pressure on the suction machine as designated
c)
Inserts the catheter before suctioning
d)
Rotates the catheter continuously during suctioning
e)
Suctions for no more than 15 seconds at a time
f)
2)
OR
When suctioning by bulb syringe is assigned:
a)
Deflates the bulb syringe prior to insertions
b)Inserts the bulb syringe into the patient’s mouth
and/or nares before suctioning
c)
Aspirates secretions
d)
IV.G.5.h
Suctioning may be assigned by either catheter or by bulb syringe. The Critical
Elements specify nursing behaviors required for successful completion of this
respiratory hygiene activity.
4.You are assigned a 79-year-old patient, post-cereberal vascular accident
(CVA). The patient has right hemiparesis, expressive aphasia, and
dysphagia. You are assigned Respiratory Management, deep breathing,
coughing and suctioning oral secretions.
a.
What steps would you take to complete this assignment?
_________________________________________________________________________
_________________________________________________________________________
b.What modification would be required because of the patient’s
age and diagnosis?
_________________________________________________________________________
_________________________________________________________________________
5.You are caring for a 6-month-old admitted with RSV bronchiolitis. Assigned
Selected Areas of Care include Oxygen Management, and Respiratory
Management (care designated includes chest percussion and postural
drainage with orophyrangeal suctioning as tolerated.)
a.Describe the actions you would take to carry out these Areas of Care.
_________________________________________________________________________
_________________________________________________________________________
b.What techniques would be different for this patient compared
to a 6-year-old?
_________________________________________________________________________
_________________________________________________________________________
IV.G.5.i
6. Reassesses respiratory status immediately after respiratory
hygiene activities
Immediately following completion of all assigned respiratory hygiene activities,
reassess respiratory status with patient in SAME position as during initial
assessment. Just as with the assessment of breath sounds prior to implementing
respiratory hygiene activities, auscultate breath sounds systematically from
side to side in both upper and lower lobes. In addition, note any change in your
patient’s breathing pattern.
Auscultate the lungs after respiratory treatment even if they were clear during
the initial assessment. Secretions may be moved or loosened during treatment
and their movement or loosening can be detected only after treatment is given.
Assessment of respiratory status after suctioning by bulb syringe is not required.
7. Records
a.Bilateral breath sounds heard after treatment in comparison
with those heard initially, related to each of the above
assessment findings
b.
c.
Respiratory hygiene activities implemented
d.
Patient response to hygiene activities implemented
Document whether the breath sounds are clear or abnormal and note the
anatomical location of these sounds. In addition document your assessment
findings related to breathing patterns, respiratory hygiene activities completed
and your evaluation of the effectiveness of respiratory hygiene activities, as well
as patient’s response to hygiene activities implemented.
An example of acceptable recording:
“Breathing pattern unlabored and regular, breath sounds clear bilaterally in
upper and lower lobes. Deep breathing and coughing times four. Breath sounds
remain clear bilaterally in upper and lower lobes after treatment; no change in
breathing pattern or chest movement. Patient tolerated activity without shortness
of breath or dyspnea.”
Examples of unacceptable recording:
“Chest movement symmetrical, breathing pattern regular but labored, breath
sounds continue to be diminished over the left lower lobe after treatment. Breath
sounds clear in left upper lobe and clear in right upper and lower lobes before
and after treatment. Tolerated well.”
IV.G.5.j
“Patient coughed effectively, moderate amount of gray sputum expectorated.
Breath sounds diminished in all lobes. After treatment all lobes clear. Breathing
pattern regular. Patient tolerated procedure well.”
6.What should be added or changed to make the two unacceptable notes
acceptable according to the Critical Elements within this Area of Care?
_________________________________________________________________________
_________________________________________________________________________
7.List assessment findings that would support the nursing diagnosis of
Ineffective Airway Clearance.
_________________________________________________________________________
_________________________________________________________________________
1. As you describe the Respiratory Management activities you are about to
implement, the patient reaches for and attempts to start Incentive Spirometry.
What should you do to ensure that your baseline assessment of breath sounds
is completed prior to the initiation of respiratory hygiene activities?
Ask the patient to please wait until you have listened to his lungs so that you can
determine the effectiveness of the treatment.
2. If the patient implements Incentive Spirometry prior to your cue to enter the
Area of Care, what should you do?
I will defer this Area of Care until later so that I can listen to his breath sounds
prior to initiating respiratory hygiene activities.
3. You are caring for a patient who is less than 24 hours s/p open cholecystectomy.
The patient is quiet, moving slowly in bed. You are assigned Respiratory
Management with deep breathing and coughing. For the following examples of
CDM, evaluate the nursing actions and score the behaviors as pass/fail for CDM.
Write a rationale for your choice.
IV.G.5.k
3.
Nursing Actions
Pass/Fail
Rationale
Verbalize that you will omit
coughing because your patient
looks uncomfortable.
Fail
It is especially important to
have this patient cough and
deep breathe because the
incision is located high in
the right upper abdominal
quadrant making it painful
to participate in respiratory
hygiene activities. Check to
see if the patient has been
medicated and splint the
incision before performing
this procedure.
Assist the patient to a sidelying position, provide a
back rub, auscultate lungs,
assist the patient to a sitting
position, instruct the patient to
breathe and cough, auscultate
lungs, assist the patient to a
comfortable position.
Fail
You will obtain a more
accurate lung assessment
if you auscultate the lungs
while the patient is upright
unless the patient can not
tolerate this position. In that
case, it would be necessary to invoke CDM and tell
the Clinical Examiner why
you were not going to position the patient to facilitate
the procedure. Instruct the
patient to splint the abdomen, take 3 deep breaths
and cough on the 3rd
expiration, repeat as
necessary and then auscultate the lungs so that you
can evaluate the treatment.
Auscultate lungs. Patient
complains that, “it hurts.”
Verbalize that you will defer
deep breathing and coughing
and that you will go to the
primary nurse and request
that the patient be medicated
for pain. One half hour after
patient is medicated, auscultate
lungs, five repetitions deep
breathing. Auscultate lungs.
Fail
You did not have the
patient cough.
IV.G.5.l
4. You are assigned a 79-year-old patient, post-cerebral vascular accident (CVA).
The patient has hemiparesis, expressive aphasia and dysphagia. You are
assigned Respiratory Management, deep breathing, coughing and suctioning
oral secretions.
a.
What steps would you take to complete this assignment?
Explain the procedure saying that after you have listened to the lungs, you
want the patient to take 3 deep breaths and cough on the third expiration.
Auscultate the lungs, instruct the patient as above, suction oral secretions
if patient can not expectorate and then reassess the lungs.
b.What modifications would be required because of the patient’s age
and diagnosis?
Ask questions to determine the patient’s understanding of your instructions.
If the patient is unable to sit up for auscultation of the lungs and respiratory
hygiene activities, you could ask the clinical examiner or a staff member to
assist you in supporting the patient in the upright position or you could
place the patient in a side-lying position to complete this Area of Care.
5. You are caring for a 6-month-old admitted with RSV bronchiloitis. Assigned
Selected Areas of Care include Oxygen Management, and Respiratory
Management (care designated includes chest percussion and postural drainage
with orophyrangeal suctioning as tolerated.)
a.
Describe the actions you would take to carry out these Areas of Care.
Auscultate lungs before and after chest percussion and postural drainage.
Monitor oxygen saturation levels to determine patient’s tolerance of respiratory
hygiene activities.
b.What techniques would be different for this patient compared to
a 6-year-old?
The technique for chest percussion and postural drainage, technique for
obtaining oxygen saturation levels, level of cooperation (would be able to ask
a 6-year-old to turn, hold a position for a brief period of time.) The 6-year-old
would be able to cough and would not require orophyrangeal suctioning.
IV.G.5.m
6. What should be added or changed to make the two unacceptable notes
acceptable according to the Critical Elements within this Area of Care?
The following information is needed to meet the recording Critical Elements.
Note 1: Coughing and deep breathing times 5 repetitions. Breathing less labored.
Patient states “breathing is easier.”
Note 2: Chest symmetrical, breathing pattern regular and slightly labored. Abnormal
breath sounds noted upper and lower lobes bilaterally. Patient took 3 deep breaths
and coughed for 3 cycles. Moderate amount of gray sputum expectorated. After
treatment all lobes clear bilaterally. Patient is not short of breath or dyspneic.
7. List assessment findings that would support the nursing diagnosis of
Ineffective Airway Clearance
1. Ineffective or absent cough
2. Inability to move airway secretions
3. Abnormal breath sound
4. Abnormal respiratory rhythm, rate and depth
IV.G.5.n
IV.G.6.a
UNIT IV
Section G.6
Wound Management
Critical Elements for Wound Management
2. Assesses wound location, type, appearance, and presence
or absence of drainage
3. When irrigation is designated:
a.
Selects the designated solution
b.Determines the appropriate temperature of the solution
(approximate)
c.
Uses an appropriate irrigation delivery system
d.
Positions a receptacle for return flow
e.
Irrigates without contaminating the wound
f.
Protects the surrounding skin from contact with the drainage
4. Cleanses the wound with the designated solution
5. Applies the designated topical preparation
6. When wound protection is required:
a.
Removes the dressing without contaminating the wound
b.
Removes the dressing without injuring the surrounding skin
c.
Disposes of the soiled dressing in the designated container
d.
Applies the dressing without contaminating the wound
e.
Secures the dressing
f.
Labels the dressing with date, time, and their initials
IV.G.6.b
7. Records
a.
Data related to wound
1)
Location
2)
Type
3)
Appearance
4)
Presence or absence of drainage
b.Measures implemented to cleanse, irrigate, and protect the
wound and surrounding skin
c.
Wound Management is the assessment of a wound and the implementation
of measures to clean, irrigate, and protect the wound and surrounding skin.
Assigned dressings may be clean or sterile, wet, moist or dry. The information
about the type of dressing required will be specified on the PCS Assignment
Kardex. Dressings may be of any size or located on any part of the body.
When assigned, remove the soiled dressing, assess the wound, irrigate or
cleanse the wound with a designated solution (when irrigation is assigned),
apply a topical preparation if assigned, and apply a new dressing. Maintain
asepsis and use Standard Precautions while performing the Critical Elements
of Wound Management.
Be aware of your glove size so you can select the appropriate size gloves when
gathering your supplies for a dressing change. If the CE provides you with gloves
that are not your size, ask for gloves in your size.
2. Assesses wound location, type, appearance, and presence or absence
of drainage
Wound assessment includes observation of the wound location, wound type
(incision, contusion, abrasion, puncture, laceration, penetrating wound,
pressure ulcer) the amount and character of drainage on the dressing, and the
appearance of the wound and wound bed. Assessment also includes observation
of the wound bed (e.g., granulation, necrotic), the presence or absence of drains
in the wound, signs and symptoms of local infection, inflammation, the progress
of healing, and condition of surrounding skin. When assessing for infection, note
redness, odor, pain, and warmth.
While you are advised to verbalize your assessment findings to alert the CE that
you are completing the assessment, you must remember to please talk to your
patient in a way that will not place this person in emotional jeopardy.
Wound Management
IV.G.6.c
1.Describe what happens during wound healing in the inflammatory,
proliferative, and maturation phases.
_________________________________________________________________________
_________________________________________________________________________
2.
What would an infected wound look like?
_________________________________________________________________________
_________________________________________________________________________
3.Describe the types of wound exudate and identify the implications of wound
exudate when present.
_________________________________________________________________________
_________________________________________________________________________
3. When irrigation is designated:
a.
Selects the designated solution
b.Determines the appropriate temperature of the solution
(approximate)
c.
Use an appropriate irrigation delivery system
d.
Positions a receptacle for return flow
e.
Irrigates without contaminating the wound
f.
Protects the surrounding skin from contact with the drainage
When the patient requires wound irrigation, the CE will designate the type of
solution to be used on your PCS Assignment Kardex. Irrigating solutions will be
at room temperature unless otherwise designated. Use of the thermometer to
determine the temperature “warm” or “iced” of the irrigating solution will not be
required.
Remember to select the appropriate equipment when irrigating a wound. For
example irrigating a wound using a bulb syringe delivers a force of 1-2 pounds
per square inch (psi) and does not effectively cleanse a wound. A 35 ml syringe
with a 19 gauge angiocath is acceptable for cleansing the wound. However,
using too much pressure could damage the wound tissue.
During the irrigation procedure, protect the surrounding skin form contact
with drainage, position the receptacle for return flow, and irrigate without
contaminating the wound.
IV.G.6.d
4. Cleanses the wound with the designated solution
5. Applies the designated topical preparation
6. When wound protection is required:
a.
Removes the dressing without contaminating the wound
b.
Removes the dressing without injuring the surrounding skin
c.
Disposes of the dressing without contaminating the wound
d.
Applies the dressing without contaminating the wound
e.
Secures the dressing
f.
Labels the dressing with the date, time and your initials
If you are assigned application of a clean dressing, use clean gloves to remove
the contaminated dressing and to apply the new dressing. An example of a
clean dressing is a gastrostomy tube insertion site dressing.
If you are assigned application of a sterile dressing, it is acceptable to use either
sterile or clean gloves to remove the contaminated dressing. Sterile gloves are
worn when applying the new dressing. When using clean gloves to remove
a soiled dressing, avoid contaminating the wound. An example of a sterile
dressing is a dressing that covers a surgical incision.
4.What are possible complications of wound healing? What signs and
symptoms would alert you to these possible complications?
_________________________________________________________________________
_________________________________________________________________________
5.How would you manage the care of a patient who has an infection with
a resistant strain of microbe such as Methcillin Resistant Staphylococcus
Aureus (MRSA) or Vancomycin Resistant Enterococcus (VRE)?
_________________________________________________________________________
_________________________________________________________________________
7. Records:
a.
Data related to wound
1)
Location
2)
Type
3)
Appearance
4)Presence or absence of drainage
Wound Management
b.Measures implemented to cleanse, irrigate, and protect
the wound and surrounding skin
c.
IV.G.6.e
Documentation for Wound Management includes data related to wound
assessment, measures implemented and patient response to the measures
implemented and it is completed using the narrative note section of the
Student PCS Response Form.
Acceptable Examples of Recording
“Left hip incision cleansed with normal saline. Wound edges are approximated,
no redness, tenderness or exudate noted. Surrounding skin intact. Dry sterile
dressing applied. Patient tolerated dressing change without complaint.”
“Moderate amount of serosanguinous drainage noted on left hip ulcer.
Wound edges separated, reddened, edematous. Surrounding skin inflamed
and edematous. Sterile dressing applied. Patient verbalized minimal discomfort
during dressing change.”
“Midline abdominal wound irrigated with normal saline solution. Wound bed
appears pink. No redness or edema of surrounding skin noted. Wound packed
with sterile normal saline soaked gauze, covered by dry sterile dressing. Small
amount of serious drainage noted, patient verbalized there is less drainage on
dressing removed today and less abdominal tenderness.”
Wound Management
1. Describe what happens during wound healing during the inflammatory,
proliferative and maturation phases.
• Inflammatory Phase (Reaction): localized redness, warmth, edema
and throbbing.
• Proliferative Phase (Regeneration): wound fills in with connective or
granulation tissue and the top of the wound closes by epitheliazation.
• Maturation Phase (Remodeling): Scar tissue forms which is usually
lighter than the surrounding skin
For a more detailed description of these phases, refer to a nursing fundamentals
textbook.
2. What would an infected wound look like?
Increasing size of ulcer, increasing pain, foul smelling drainage, redness
around ulcer.
IV.G.6.f
3. Describe the types of wound exudate and identify the implications of wound
exudate present.
Types of exudates include serous (similar to serum, thin and watery) sanguinous
(bloody), serosanguinous (serum containing blood) all of which are normal
during the healing process and purulent (containing pus), which would be
indicative of infection.
4. What are possible complications of wound healing? What signs and symptoms
would alert you to these complications?
Hemorrhage: Depending on the extent of the hemorrhage, the dressing could
be saturated with bright red blood. Patient would possibly be diaphoretic with
an increase in pulse and/or decrease in blood pressure.
Infection: Wound edges may appear red, tender and edematous. Any discolored
drainage that is foul smelling on dressing and the wound itself.
Necrosis: Wound would appear grey, dark brown or black due to tissue death.
Tissue Dehiscence: Wound opens and the edges are not approximated. There
may be an increase in serosanguinous, sanguinous, drainage.
Evisceration: Underlying organs may protrude through the wound.
5. How would you manage the care of a patient who has an infection with a
resistant strain of microbe such as Methicillin Resistant Staphylococcus Aureus
(MRSA) or Vancomycin Resistant Enterococcus (VRE)? What are the precautions
you would take?
Maintain contact isolation, following hospital policy as posted outside the patient’s
room. Maintain Standard Precautions as with all patients.
IV.H
UNIT IV
III
Section H
A
Enteral Feeding
Irrigation
Medications
Patient Teaching
IV.H.1.a
UNIT IV
Section H.1
Critical Elements for Drainage and Specimen Collection
2. When drainage collection is assigned:
a.
Assesses the amount and color of drainage
b.
Cleans the surrounding skin or tissue when assigned
c.
Inserts the tube into the appropriate body cavity
d.
When drainage is by tube:
1)
Maintains or attaches tube to container
2)
Maintains patency of the tube
3)
Maintains drainage by gravity or suction apparatus
Removes the tube when assigned
e.
3. When specimen collection is assigned:
a.
Obtains the designated specimen
b.Places the specimen in the designated container
or on the designated surface
c.
Ensures that the specimen is labeled
d.
Places specimen in designated area for transport
4. Records data related to drainage amount and color
5. Records data related to specimen collection
6. Documents and/or reports disposition of specimen
Drainage and Specimen Collection is the removal of body secretions by
gravity or suction, by a tube or other means, from a body cavity or wound,
including the care and protection of the surrounding skin and, when
designated, specimen collection.
IV.H.1.b
While performing the Critical Elements for Drainage and Specimen Collection
you may perform techniques such as inserting or monitoring tubes and/or
collection devices. For example, you could be assigned to insert an indwelling
urinary catheter or to monitor drainage form an NG tube, wound drain, or other
collection devices. Insertion of nasogastric tubes is not required as part of the
examination. Refer to your fundamentals of nursing or clinical skills textbooks
for established guidelines for drainage and specimen collection.
Drainage from a continuous system (e.g., continuous suction NG or Foley
catheter) is not measured as output during the PCS unless hourly I&O is
assigned. When hourly I&O is assigned, the time for measurement will be
written on the PCS Assignment Kardex. Remember to use Standard Precautions
when collecting drainage or specimens.
2. When drainage collection is assigned:
a.
Assesses the amount and color of drainage
b.
Cleans the surrounding skin or tissue when assigned
c.
Inserts the tube into the appropriate body cavity
d.
When drainage is by tube:
1)
Maintains or attaches tube to container
2)
Maintains patency of the tube
3)
Maintains drainage by gravity or suction apparatus
Removes the tube when assigned
e.
Observe and document drainage characteristics including color, amount,
viscosity, and odor. Proper use of descriptive terms is necessary for professional
communication as well as for objective evaluation of progress or lack of
progress toward the desired outcome.
Drainage collection by tube can include nasogastric/gastrointestinal
decompression tubes, chest tubes, urinary catheters, wound drainage collection,
and ostomies. Monitoring electric or negative pressure suction (e.g., low wall
suction), portable wound suction (e.g., Jackson Pratt, Grenade, Hemovac) and
Foley drainage systems as well as maintaining patency may be a part of this
Critical Element.
IV.H.1.c
1.For the following situation, rate the student’s CDM as Pass/Fail and
give your rationale for your rating. Include the information that should
be verbalized to the Clinical Examiner.
Decision
Pass/Fail
Rationale
Statement to the Clinical
Examiner
The assignment is to apply
a urine collection bag to an
infant. The student decides
not to do this during the PCS
because the child is crying.
3. When specimen collection is assigned:
a.
Obtains the designated specimen
b.Places specimen in designated container or on
the designated surface
c.
Ensures that the specimen is labeled
d.
Places specimen in designated area for transport
Collection of specimens include: urine, stool, sputum, and wound drainage.
You will not be drawing blood or performing fingerstick glucose monitoring.
Orientation to equipment used for specimen collection will be provided. Be
familiar with general guidelines for specimen collection prior to the CPNE (e.g.,
urine, sputum, and stool). Location of specific containers and the designated
area for transport will be identified during the unit orientation.
Policies specific to the test site will be designated on the PCS Assignment
Kardex. Unit policy and procedure manuals will be available to you during
the examination as resources for finding the answer to questions specific to
specimen collection.
4. Records data related to drainage amount and color
5. Records data related to specimen collection
6. Documents and/or reports disposition of specimen
Documentation includes recording of your assessment findings related to
the drainage and specimen collection in the narrative notes on the PCS
Recording Form.
IV.H.1.d
“Small amount of thick green fluid draining via nasogastric tube to low wall
suction. Nares red and crusted. Cleansed nares with normal saline, water-based
lubricant applied. Nasogastric tube repositioned, taped securely.”
“Chest tube draining, a small amount of serous drainage less than 50 ml in
drainage chamber. Occlusive vaseline gauze dressing intact over chest tube
insertion site. No signs and symptoms of infection. No kinks in tubing. All
connections taped securely. Chest tube collection set-up below chest level.”
“Nasogastric tube draining via intermittent low wall suction with large amount
of bile-colored drainage. Nares care with no redness noted.”
“Stool culture was obtained, labeled, and sent to the lab.”
Drainage Collection/Specimen Analysis
1. For the following situation, rate the student’s CDM as Pass/Fail and give your
rationale for your rating. Include the information that must be verbalized to the
Clinical Examiner.
Decision
Pass/Fail
The assignment is to apply
Fail
a urine collection bag to an
infant. The student decides
not to do this during the PCS
because the child is crying.
Rationale
It is important to obtain
the urine specimen as
ordered for diagnostic
purposes.
Statement to the Clinical
Examiner
Defer applying the urine
bag until later when the
child is calmer or have the
parent hold the child while
you apply the bag and
then comfort the child.
IV.H.2.a
UNIT IV
Section H.2
Enteral Feeding
Critical Elements for Enteral Feeding
2. For all feedings:
a.
Selects the prescribed feeding
b.
Positions the patient to promote feeding
c.
Delivers the prescribed feeding
3. When assistance with feeding is designated:
a.
Chooses an appropriate feeding device
b.
Burps an infant under six months of age periodically, as necessary
4.Administers the feeding at room temperature unless
5. When intermittent tube feeding is designated
a.
Determines the amount of feeding to be administered
b.
Calculates the drops per minute
c.Verifies the location of a nasogastric tube by using one of the
following methods before initiating gastric feeding, unless
contraindicated by:
1)
Aspirating gastric contents
OR
2)Instilling 10 –20 ml of air into the stomach while
auscultating (5 ml for children under 2 years of age)
d.
Measures gastric residual before initiating feeding
e.
Reinstills gastric residual unless contraindicated
f.Initiates the prescribed feeding within ± 30 minutes
of scheduled time
g.Regulates the feeding rate to be delivered within the specified time
when required by either:
IV.H.2.b
1)Adjusting the flow to within ±5 drops per minute of the
calculated number of drops per minute
OR
2)Adjusting the flow rate for the enteral feeding pump to the
exact number required to deliver the prescribed volume
6. When continuous tube feeding is designated:
a.
1)
a)
OR
b)Documenting the flow rate setting on the enteral feeding
pump on the PCS Recording Form
2)
a)Adjusting the flow to within ±5 drops per minute of the
OR
b)Adjusting the flow rate of the enteral feeding pump to the
b.Verifies the location of the nasogastric tube at least once during
the PCS by one of the following methods, unless contraindicated:
1)
OR
2)Instilling 10 –20 ml of air into the stomach while auscultating
(5 ml for children under 2 years of age)
When measurement of gastric residual is designated:
c.
1)
Measures gastric residual
2)
3)
7. Records the kind of oral feeding administered
8. Records the name and strength of the feeding product for
a patient receiving a tube feeding
9. Records the amount of feeding administered
Enteral Feeding
IV.H.2.c
Enteral Feeding is the administration of nutrients by bottle, tube, or other
device to infants, children, or adults who require assistance with feeding.
Gavage feeding may include the administration of enteral fluids with a syringe
or enteral feeding pump. Nasogastric, gastrostomy, jejunostomy, or PEG tube
feedings may be assigned. You will not be required to insert feeding tubes.
A feeding includes both the formula and any fluid ordered to follow the formula.
All of the fluid administered during intermittent feedings is recorded as intake
for the PCS. Volumes of fluids administered during continuous feeding will
not be included in the intake total for the PCS unless the feeding needs to be
replenished or discontinued. If replenishment of the feeding is required, the
examiner will write the formula type and rate of infusion on the Kardex and
write the volume of feeding to be documented as intake.
It is common practice to reinstill gastric contents once the amount of gastric
residual has been established. Not reinstilling gastric contents could lead to a
disturbance of the patient’s electrolyte balance.
Case Study
You are assigned an intermittent bolus tube feeding via NG tube. The
patient complains of nausea and vomits around the tube. You would
elect to omit the Area of Care. You verbalize to the CE that you will
hold the feeding and report to the primary nurse that the feeding was
held since the patient vomited.
2. For all feedings
a.
Selects the prescribed feeding
b.
Positions the patient to promote feeding
c.
Delivers the prescribed feeding
The type and strength of feeding or formula including flow rate, kind of feeding,
or formula, dilution, and the mechanism for delivery, will be designated on the
PCS Assignment Kardex.
The CE will also provide information about any flush required before and after
the feeding. Choose the appropriate formula and prepare the ordered strength
prior to administration, position the patient to promote flow of feedings, and
deliver the prescribed feeding. You are encouraged to check the label on
feedings carefully before opening the container.
IV.H.2.d
Positioning the patient to promote feeding means you must maintain the head
of the patient’s bed in an elevated position during all feedings (continuous and
intermittent) or turn a continuous feeding off if the head of the bed is expected
to be lowered. In addition, avoid lowering the head of the bed for a patient who
has recently finished an oral feeding or an intermittent tube feeding.
Example of Diluting Enteral Feeding Formula
Your patient is receiving ¼ strength enteral feeding solution via an enteral
feeding pump at 75 ml per hour. Prepare enough diluted formula to infuse over
an eight-hour period. Each can of enteral feeding formula contains 240 ml.
Calculate the total volume to be infused over an 8 hour period.
75 ml/hr × 8 hours = 600 ml
Since the strength of the formula desired is ¼ strength, then ¼ of the total
volume to be infused is the volume of the formula and ¾ of the total volume to
be infused is water. Therefore, divide 600 ml by 4 to determine the volume of
enteral feeding formula.
600 ml ÷ 4 = 150 ml
Now you are ready to mix the 150 ml enteral feeding formula with 450 ml water.
The amount of water is three times the amount of enteral feeding formula
(150 ml × 3 = 450 ml) or the total volume minus the amount of enteral feeding
formula (600 ml – 150 ml = 450 ml)
1a.Calculate the total feeding amount to be delivered over an eight hour
period. The pump is set @ 60 ml/hr
_________________________________________________________________________
_________________________________________________________________________
b.Complete the chart below to determine the amount of enteral feeding
formula and amount of water for the following feeding concentrations:
Amount of Liquid Feeding
+
Amount of Water
=
Strength of Solution
ml
ml
½ strength
ml
ml
3/4 strength
ml
ml
Full strength
Enteral Feeding
IV.H.2.e
3. When assistance with feeding is designated:
a.
Chooses an appropriate feeding device
b.
Burps an infant under 6 months of age periodically as necessary
Apply principles of growth and development when feeding a child. You
check with the parent or the patient’s nurse to determine the child’s feeding
preferences.
4. Administers the feeding at room temperature unless
2.You are assigned bottle feeding for a 6-month-old infant. You need to weigh
the baby before feeding. The baby is crying loudly. What should you do?
_________________________________________________________________________
_________________________________________________________________________
5. When intermittent tube feeding is designated
a.
b.
Calculates the drops per minute
When an intermittent feeding is assigned, calculate the drops per minute for
gravity flow administration. The CE will write the drop factor of the tubing on the
PCS Assignment Kardex and orient you to the equipment used during the unit
orientation. You should be able to regulate the equipment and to provide the
correct amount of fluid in the specified period of time.
c.Verifies the location of a nasogastric tube by using one of the
following methods before initiating gastric feeding, unless
contraindicated by:
1)
OR
2)Instilling 10-20 ml of air into the stomach while
auscultating (5 ml for children under 2 years of age)
Verify the location of the nasogastric tube using one of the stated methods
listed in the Critical Elements for successful completion of this Area of Care.
If you attempt to check placement by aspirating for stomach contents and
do not get any gastric contents, remember to check placement by another
method. Measure the gastric residual when assigned. The CE may designate
IV.H.2.f
at what volume of gastric residual the tube feeding must be held. If this is not
written on your PCS Assignment Kardex, ask the CE or assigned staff nurse at
what volume the tube feeding should be held. After measuring and reinstilling
gastric residual, document your findings on the PCS Recording Form.
If the hospital policy is to check placement of G-tubes or J- tubes, the CE will
designate it on your PCS Assignment Kardex.
d.
Measures gastric residual before initiating feeding
e.
f.Initiates the prescribed feeding within ± 30 minutes of
scheduled time
g.Regulates the feeding rate to be delivered within the specified time
when required by either:
1)Adjusting the flow to within ±5 drops per minute of the
OR
2)Adjusting the flow rate for the enteral feeding pump to the
Monitor the feeding and maintain the prescribed delivery over the specified
time. Regulate the feeding to ± 5 drops per minute for a gravity drip feeding.
The enteral feeding pump is set to the exact number of the volume to be
delivered. If the feeding is assigned as a bolus, raise or lower the syringe
attached to the tube to increase or decrease the flow rate of the feeding.
3.You are assigned to give a patient a bolus feeding. After you check tube
placement, you pour the feeding into the barrel of the syringe. The feeding
will not flow.
a.
What should you do?
_________________________________________________________________________
_________________________________________________________________________
b.
What precautions do you need to follow when handling feeding tubes?
_________________________________________________________________________
_________________________________________________________________________
Enteral Feeding
IV.H.2.g
4.Your patient care assignment is an 8-month-old infant with a gastrostomy
tube, who is to receive a 120 ml bolus feeding of formula. At the time of
your PCS, the infant is sleeping, her mother is by the bedside. What actions
do you take before starting the feeding?
_________________________________________________________________________
_________________________________________________________________________
6. When continuous tube feeding is designated:
a.
1)
a)
OR
b)Documenting the flow rate setting on the enteral feeding
pump on the PCS Recording Form
2)
a)Adjusting the flow to within ±5 drops per minute of the
OR
b)Adjusting the flow rate of the enteral feeding pump to the
the PCS by one of the following methods, unless contraindicated:
1)
OR
2)Instilling 10 –20 ml of air into the stomach while auscultating
When measurement of gastric residual is designated:
c.
1)
Measures gastric residual
2)
3)
For continuous tube feedings, within 20 minutes after beginning the
Implementation Phase, verify the accuracy of the flow rate, adjusting the flow
to ±5 gtts/min of the calculated drops per minute or the exact number required
to deliver the prescribed volume on an enteral feeding pump. In addition, verify
the location of a nasogastric feeding tube at least once during the PCS and
measure gastric residual when designated.
IV.H.2.h
5.You are assigned to care for a woman who is 79 years old, who is receiving
Jevity 75 ml/hr via an enteral feeding pump. You check and measure gastric
residual to be 125 ml. What should you do?
_________________________________________________________________________
_________________________________________________________________________
7. Records the kind of oral feeding administered
8. Records the name and strength of the feeding product for a
patient receiving a tube feeding
9. Records the amount of feeding administered
Recording of amount of feeding is required for intermittent (bolus) feedings. For
continuous feedings, recording the amount of feeding administered is required
only when the feeding is totally infused or discontinued. For all tube feedings,
record the name of the feeding product as well as the strength of the feeding
product (example: full strength, ½ strength). Record specific solid food intake
only when it is required by the patient’s condition.
6.a.Write a nursing care plan for a patient receiving enteral feeding (via a peg
tube) following oral surgery for removal of a cancerous lesion of the mouth.
Nursing Diagnosis: ______________________________________________________
_________________________________________________________________________
Outcome: _______________________________________________________________
_________________________________________________________________________
Interventions: 1._________________________________________________________
_________________________________________________________________________
2._________________________________________________________
_________________________________________________________________________
Enteral Feeding
IV.H.2.i
Enteral Feeding
1a.Calculate the total feeding amount to be delivered over an 8 hour period.
The pump is set @ 60 ml/hr.
480 ml
1b.Complete the chart below to determine the amount of enteral feeding formula
and amount of water for the following feeding concentrations:
Amount of Liquid Feeding
+
Amount of Water
=
Strength of Solution
300 ml
300 ml
½ strength
450 ml
150 ml
3/4 strength
600 ml
0 ml
Full strength
2. You are assigned a bottle feeding for a 6-month-old infant. You need to weigh
the baby before feeding. The baby is crying loudly. What should you do?
Comfort the infant with a pacifier if available and by talking to the child. Weigh and
dress the child as quickly as possible.
3a. You are assigned to give a bolus feeding. After you check tube placement, you
pour the flush solution into the barrel of the syringe. The fluid will not flow. What
should you do?
Raise the level of the syringe to increase gravity pressure. If that does not work,
apply gentle pressure with syringe plunger to increase pressure until the flow is
established. If you are still unsuccessful, irrigate the tube with the piston syringe
and water. The tube may be clogged.
3b. What precautions do you need to follow when handling feeding tubes?
You need to wear clean gloves because you are in danger of coming in contact with
gastric secretions.
4. Your patient care assignment is an 8-month-old infant with a gastrostomy tube,
who is to receive a 120 ml bolus feeding of formula. At the time of your PCS, the
infant is sleeping; her mother is by the bedside. What actions do you take before
starting the feeding?
Determine if the position of infant is appropriate for the feeding, verify that the type
of formula at the crib side is correct, determine if you have all of the necessary
equipment at the crib side to do the feeding, measure gastric residual, reinstill
gastric residual unless contraindicated.
IV.H.2.j
5. You are assigned to care of a woman who is 79 years old, who is receiving Jevity
75 mls/hr. via an enteral feeding pump. You check and measure gastric residual
to be 125 mls. What should you do?
Reinstill the gastric residual and check your assignment Kardex to be sure there
is no written parameter for holding the tube feeding when the gastric residual is a
designated number of mls. If no parameter is indicated on the assignment Kardex,
ask the Clinical Examiner or the primary nurse what the hospital policy is in this
situation.
6. Write a nursing care plan for a patient receiving enteral feeding via a peg tube
following oral surgery for removal of a cancerous lesion of the mouth. What are
the possible related factors?
Label: R
isk for altered nutrition: less than body requirements related to altered oral
mucosa and impaired swallowing.
Outcome: Patient will be free of gastric distress during tube feedings.
Interventions: 1) Measure gastric residual prior to feeding.
2) Administer enteral feeding as prescribed
IV.H.3.a
UNIT IV
Section H.3
Irrigation
Critical Elements for Irrigation
1. Selects the designated solution
2. Determines the appropriate temperature of the solution when necessary
3. Positions the patient to facilitate irrigation
4. Verifies the correct placement of the tube
5. Instills the solution into the designated area
6. Controls the rate of flow of the solution
7. Positions the receptacle for return flow
8. Records the kind of irrigating solution used
9. Records the amount of irrigating solution used
Irrigation is the introduction of fluid into and drainage from any body
orifice or cavity.
Irrigations may be intermittent or continuous. If a particular receptacle is
required to collect the irrigation solution, the CE will show it to you during the
unit orientation. Sterile technique is used to avoid introducing microorganisms
into a wound or body cavity such as the bladder. Your assignment may include
irrigations of:
• The eye
• The ear
• The nose
• Wounds
• The bowel (enemas)
• The vagina (douches)
• The bladder
• Tubes (nasogastric)
IV.H.3.b
1. Selects the designated solution
2. Determines the appropriate temperature of the solution when necessary
3. Positions the patient to facilitate irrigation
4. Verifies the correct placement of the tube
5. Instills the solution into the designated area
6. Controls the rate of flow of the solution
7. Positions the receptacle for return flow
Consider the patient’s safety and well-being as you prepare the patient for the
procedure. The CE will designate the appropriate solution and temperature, if
appropriate, on the PCS Assignment Kardex. The CE will also designate which
body cavity, wound, or tube requires irrigation.
8. Records the kind of irrigating solution
9. Records the amount of irrigating solution
Record the amount and kind of irrigating solution used. Documentation is
important to communicate that the procedure was completed safely and
correctly. In addition, your recording of the patient’s response will let subsequent
caregivers know how effective the treatment was. Recording for the Area of Care
“Irrigation” is done by narrative note, in the PCS Response Form. Remember to
identify the hospital’s policy of whether or not the irrigation is included in the
I&O totals.
Examples of appropriate Recording:
“NG tube irrigated with 30 ml of NS solution at 1000. Light green fluid
returned via low suction; patient states they no longer feel nauseated.”
“Patient placed in left Sims position. Fleets Retention enema, 100 mls
administered rectally. Patient instructed to retain as long as possible.
Assisted to bathroom. Large amount of brown formed stool and enema
evacuated by patient.”
“Irrigated left ear with 100 mls warm normal saline. Clear fluid with small
brown flecks returned. Tolerated procedure without pain or discomfort.
States his hearing is better now.”
Irrigation
IV.H.3.c
1.For the following examples, evaluate the sample recording for meeting
the Critical Elements. Rewrite any documentation that does not meet the
standard measured in the CPNE.
Pass/Fail
Rationale/Rewrite
Continuous irrigation infusing to
wound behind Left ear. Tolerated well.
Soapsuds enema (SSE) given in left
lateral sims position. Large amount
brown fluid and stool returned.
Eye irrigated. Contacts removed.
Patch applied.
Case Study
You are assigned an 84-year-old male s/p benign prostatic hypertrophy.
The patient has continuous normal saline (NS) irrigation at 60 gtts/min
to prevent clotting and obstruction of the catheter. Assessment findings
include decreased urinary output, increased number of clots in urine,
patient c/o abdominal pain, and notable abdominal distention. Your
nursing intervention is to report change in status to primary RN because
you suspect an obstruction of catheter.
IV.H.3.d
Irrigation
1.For the following examples, evaluate the sample recording for meeting the
Critical Elements. Rewrite any documentation that does not meet the Critical
Elements measured in the CPNE.
Pass/Fail
Continuous irrigation infusing to wound
behind Left ear. Tolerated without
discomfort.
Fail
Soapsuds enema (SSE) given in left
lateral sims position. Large amount
Fail
Eye irrigated. Contacts removed.
Patch applied.
Fail
Rationale/Rewrite
Incomplete, no mention of kind of
solution.
Rewrite: continuous normal saline
irrigation infusing to wound behind
left ear.
Incomplete, no recording of amount
of solution.
Rewrite: SSE 1000 mls given in left
lateral Sims position. Large amount
Incomplete, no mention of kind or
amount of solution used or which eye
was irrigated.
Rewrite: Contact lens removed from
left eye, irrigated with 30 mls normal
saline. Patch applied to left eye.
IV.H.4.a
UNIT IV
Section H.4
Medications
Critical Elements for Medications
1. Complies with established guidelines related to medication
administration
2. Selects the prescribed medication using the hospital medication
administration record (MAR)
3. Measures the prescribed dosage
4. Identifies the patient immediately before administering the medication
by verifying two of the following pieces of patient information
a.
Patient name
b.
Date of birth
c.
5. Uses the correct needle size for injections
6. Uses the prescribed route and/or site for administering medications
7. Administers the prescribed medication to the designated patient
8. Administers the medication within 30 minutes of the scheduled time
9. When IV Medication is to be administered:
a.Records the correct flow rate in drops per minute for gravity flow
or milliliters per hour for infusion control devices (ICDs) on the
PCS Recording Form before administering the medication
b.Assess the insertion site for dislocation, infiltration, or other
complications immediately before administering the medication
by using one of the following methods:
1)
OR
2)
Clears air from the tubing before initiating flow
c.
IV.H.4.b
d.
When an intermittent venous access device is used:
1)
2)Flushes with the designated solution prior to medication
administration
3)Flushes with the designated solution after medication
administration
4)
Aspirates for blood return unless contraindicated
Records the flush solution used on the PCS Response Form
e.Regulates the flow to deliver the prescribed amount in the
designated period of time (±5 drops pr minute for gravity flow
or the correct ICD setting)
10. R
ecords the medications administered on the hospital MAR within
30 minutes after administration
11. R
ecords on the PCS Recording Form data related to condition of
insertion site for peripheral, central, or implanted venous access
devices
Medications is the administration of medications by any route: oral,
intramuscular, intravenous, subcutaneous, or other routes. (Medications
must be completed successfully at least once during the CPNE)
Medications are assigned at least once during the CPNE. Although the CE will have
written the medication orders for the medication you will be assigned on the PCS
Assignment Kardex, use the hospital medication administration record (MAR)
to administer the medication(s) to the patient. The CE will verify the accuracy of
medication orders transcribed on the hospital MAR with the physician’s order prior to
transcribing them on to the PCS Assignment Kardex.
You may be assigned up to six medications by no more than two routes. Routes of
administration may include subQ, IM sublingual, oral, eye, ear, vaginal, rectal, inhaler,
topical, via NG/G tube, and/or intravenous mini bottle/bag. IV Push medications
are performed only in the Simulation Laboratory portion of the CPNE. Multiple
medications assigned during a PCS will be designated for the same time. You will not
be assigned experimental or research protocol medications or blood/blood products.
The CE will write any hospital-specific protocols on the PCS Assignment Kardex.
For example, if subcutaneous heparin is assigned and there is a specific hospital
policy that states that heparin subQ is to be administered in the abdomen only, the
CE will inform you of this policy by writing “administer in the abdomen only” on the
PCS Assignment Kardex. During the examination you may review any unfamiliar
medications in your drug reference book or medication reference book on the unit.
Your CE will tell you where the medication reference books are located on the unit.
The CE will orient you to the location and storage of medications, equipment,
and supplies needed to carry out your assignment. If the tubing on a secondary
administration set is to be changed your CE will inform you of this expectation.
Medications
IV.H.4.c
administration
Examples of established guidelines for medication administration include
checking the apical pulse before administering digitalis, taking a blood pressure
before administering anti-hypertensives, and knowing the compatibility of IV
medications.
Be alert for guidelines that are medication specific. To determine medicationspecific guidelines, be sure to read package inserts, your drug reference book,
or a Physician’s Desk Reference (PDR). An example of a medication-specific
guideline is the manufacturer’s caution to “not expel the air bubble” before
administering Lovenox (enoxaparin sodium).
Medication administration may vary from unit to unit (e.g., medication
carts, Pyxis systems, nurse servers). However, the standard of medication
administration is to be met within any setting to ensure safe medication
delivery (e.g., adhering to the 6 rights of medication administration).
2. Selects the prescribed medication using the hospital medication
You should know the action, use, and side effects of any medications you
are to administer and to implement all pertinent nursing measures to ensure
their safe administration. Look for any guidelines to follow on the MAR;
e.g., “Hold if systolic BP < 90.”
The Critical Element is an active step. With the MAR in hand, physically check
the medications to be given by comparing each medication written on the MAR
to the available medications.
The CE will evaluate your performance of “selects the prescribed medication
using the hospital MAR” after asking, “Are these the medications you will
be administering?” Once you hear this question, take a minute to make sure
you are in compliance with safe medication administration before answering
affirmatively that you are ready for the CE to confirm that you have selected the
right medication.
IV.H.4.d
1.What should you do if the patient’s medications are labeled by their generic
names and the MAR lists the medications by their trade names?
_________________________________________________________________________
_________________________________________________________________________
2.What specific nursing actions should you implement prior to giving
medications such as digoxin, morphine sulfate, insulin, or heparin?
_________________________________________________________________________
_________________________________________________________________________
3.What should you do if you have been assigned to give an anti-hypertensive
medication and your patient’s blood pressure, when you checked it, was
90/50? The patient’s baseline BP was 150/90.
_________________________________________________________________________
_________________________________________________________________________
4.What laboratory test values should you check before administering
diuretics, digitalis preparations, and anticoagulants?
_________________________________________________________________________
_________________________________________________________________________
Be familiar with common systems of medication measurements (e.g., the
metric system). Any formula is acceptable for the calculation of a correct dose.
Calculators may be used; however, it is unacceptable to pre-program a calculator
with a calculation formula. The CE will orient you to any special equipment
needed to measure the correct dose, e.g., a pill cutter. For medications that are
to be reconstituted or diluted, the CE will provide specific instruction regarding
the type and volume of diluent to be used when preparing the powdered/liquid
medication and the dosage strength of the resulting solution.
The CE will evaluate your accuracy in measuring the prescribed dose after
asking, “Are these the medications you will be administering?” Remember, this
is the time to do your final check for the right medication(s) and right dose(s).
Before you answer, verify that you have the right medication(s) for the right
patient and have measured the prescribed dose(s). Once you are positive, then
answer yes. This is the point of evaluation for Critical Elements 2 and 3. After the
CE verifies you have the right medication and right dosage you will be allowed to
continue to the bedside to administer the medications.
Medications
IV.H.4.e
For any medications that come prefilled in a syringe with a rubber sheath
covering the needle, the CE will verify the dosage to be administered at the
bedside. Since the seal on the rubber sheath needs to be broken in order to
expel air or discard unwanted medication from the syringe, you will be allowed
to prepare the correct dosage at the bedside prior to administration. The purpose
of this method is to keep you from uncovering and resheathing the needle and
exposing yourself to a needle stick injury. The rubber sheath on this type of
injection system is very penetrable and once removed is difficult to replace/
resheath.
5.You are to administer furosemide (Lasix) 20 mg, however 40 mg tablets are
available. How would you prepare to give the correct dose?
_________________________________________________________________________
_________________________________________________________________________
6.Your patient is NPO and is receiving nutrition and hydration through
a G-tube.
a.How would you prepare a tablet for administration via this G-tube for
an adult and for a child?
_________________________________________________________________________
_________________________________________________________________________
b.How would you prepare a nonsustained action capsule for
administration via this G-tube?
_________________________________________________________________________
_________________________________________________________________________
7.Not all insulin syringes are marked using the same system of measured
increments for units of insulin. Some syringes are marked by 1-unit
increments and some are marked by 2-unit increments. How will you be
sure you have drawn up the correct dose?
_________________________________________________________________________
_________________________________________________________________________
8.Suppose you are using a disposable injection unit such as a Tubex or
Carpujet system. These unit dose medications usually contain an overfill
and air in the cartridge. How would you handle such a situation in order to
measure the correct dose of injectable medication?
_________________________________________________________________________
_________________________________________________________________________
IV.H.4.f
by verifying two of the following pieces of patient information:
a.
Patient name
b.
Date of birth
c.
Identify your patient immediately prior to administering any medications.
Although you will be assigned to only one patient during each PCS, the
importance of identifying your patient immediately before administering the
medication will not change. Although you may have identified your patient
earlier in the PCS, it is expected that you will identify your patient immediately
before administering the medication.
The preferable method of patient identification is comparing the MAR with the
patient’s ID band. If the patient is alert and oriented, you may ask the patient to
state their name and birth date as 2 pieces of identifying information. Be very
deliberate in this action because the CE may not be able to observe you visually
scanning the ID. If the patient is unresponsive or confused, you can bring the
MAR into the patient’s room and verify the patient’s name and medical record
number on the ID band. It is acceptable to ask a parent to identify a child. When
a small child or infant has no ID band, check the crib to see if the ID band has
been affixed to the crib.
9.What would you do if you prepared the medications to be administered,
walked in the room, and found your patient’s ID band on the floor near
the bed?
_________________________________________________________________________
_________________________________________________________________________
10.How would you identify a disoriented or confused patient who is not
wearing an ID band?
_________________________________________________________________________
_________________________________________________________________________
Medications
IV.H.4.g
5. Uses the correct needle size for injection
The correct needle size is used for the administration of injectable medications.
Familiarize yourself with the variety of needle sizes and types of equipment
available for administering injections. Some prefilled syringes are packaged
with needles attached. Your CE will orient you to the location of medication
administration equipment on the unit.
Knowledge of growth and development is helpful when choosing the appropriate
needle size.
11.While you are drawing up the medication, you realize you are using the
wrong needle size. What should you do?
_________________________________________________________________________
_________________________________________________________________________
Intramuscular injections may be given in ventrogluteal, vastus lateralis, and
dorsogluteal sites. The ventrogluteal site is the preferred site for IM injections
as this site is located away from large blood vessels, nerves and bone. Z-Track
method presents “tracking” and is used for administering medications that are
especially irritating to subcutaneous and nerve tissue.
Palpate the bony landmarks when administering an IM injection to ensure
proper site identification. You will need to be familiar with pediatric variations
regarding site selection for the administration of IM medications. For example,
IM injections in the upper arms are rarely done in younger children due to small
muscle mass in the arms.
The first step in ensuring that you will be administering the medication to the
designated patient is to use the MAR to identify the patient (using two pieces of
information) immediately before administering the medication. Once you have
determined that the patient is the designated patient, administer the medication,
then determine whether the patient has actually taken the medication.
8. Administers the medication within 30 minutes of the scheduled time
Consider how long it will take you to prepare the medications. Consider the
steps involved and the time the medication is to be administered. Don’t forget to
allow enough time to look up unfamiliar medications.
IV.H.4.h
12.Your assignment is to administer an IV medication by secondary infusion.
Your patient has a primary IV infusing via an ICD. How would you manage
the ICD to deliver the medication at the appropriate rate?
_________________________________________________________________________
_________________________________________________________________________
13.What would you do if a baby spit out part of the medication dose you
administered?
_________________________________________________________________________
_________________________________________________________________________
14.You are assigned to administer heparin subQ and you know from your
reading that the preferred injection site for heparin subQ is the abdomen.
When you approach the patient and expose the abdomen, you find that
the abdominal incision and dressing cover most of the available area for
injection. What should you do?
_________________________________________________________________________
_________________________________________________________________________
15.You enter the patient’s room to give Lovenox 30 mg per order. The patient
tells you she just sneezed and that her nose is now bleeding. You do not
see any blood, but she says she can taste the blood. How should you
proceed?
_________________________________________________________________________
_________________________________________________________________________
9. When IV medication is to be administered:
a.Records the correct flow rate in drops per minute for gravity flow
or milliliters pr hour for infusion control devices (ICDs) on the PCS
Recording Form before administering the medication
The CE will designate how the IV medication is to be administered. IV
medications may be administered via gravity, infusion pump, or mini infuser.
In addition, the CE will designate whether the IV medication is to be infused
through an existing IV or through an intermittent venous access device.
Prior to initiating and regulating an IV medication, write the calculated flow
rate in gtts/min for a gravity flow administration or ml/hr for administration by
infusion control device on the PCS Recording Form. You may use a calculator. If
the calculation for drops per minute results in a fraction (e.g., 16.6 gtts/min), it is
acceptable to round up or down to a whole number (e.g., 16 or 17).
Medications
IV.H.4.i
IV medications may be supplied premixed in a minibottle, minibag, or syringe.
However, you may be required to reconstitute a medication in powder form and
dilute it in a designated volume of IV solution. Your CE will write any necessary
data needed for calculation of the flow rate on the PCS Assignment Kardex.
Example of flow rate calculation for an IV medication administered by
gravity flow:
The assignment designated on the PCS Assignment Kardex includes
Ampicillin 500 mg in 50 ml normal saline
IV mini bottle to run over 20 minutes
Gtt factor 15 gtt/ml
Flow rate (gtt/min) = Volume to be administered (ml) × drop factor of the tubing
(gtt/ml) _ _________________________________________________________
Time to be administered (minutes)
To determine flow rate, insert the known values for the volume to be
administered, drop factor of the tubing, and time to be administered.
Calculate by multiplying and dividing as designated by the formula.
Flow rate (gtt/min) =50 ml × 15 gtt/ml
20 minutes
Flow rate = 37.5 gtt/min
Since the answer includes a fraction, choose to round up or down to the nearest
whole number to get the rate that you will use to regulate the flow of the IV
medication. You would write “37 gtts/min” on the PCS Recording Form prior to
hanging the medication. (38 gtts/min would also be acceptable.)
16. Calculate:
Erythromycin 500 mg in 100 ml normal saline IV
To run over 30 minutes
Tubing drop factor = 15 gtt/ml
What is the flow rate that you will regulate when administering
this antibiotic?
_________________________________________________________________________
_________________________________________________________________________
IV.H.4.j
Example of flow rate calculation for an IV medication administered by infusion
control device:
Most ICDs will deliver fluid volume in mls/hr. To determine the flow rate of the
IV medication when it is to be infused in less than an hour (i.e., 30 minutes,
20 minutes), remember the following rule:
Divide 60 minutes by the time to infuse the medication. Multiply the answer
by the volume to determine the ICD setting (the volume that will be infused
in 1 hour).
The assignment designated on the PCS Assignment Kardex includes:
Ampicillin 500 mg in 50 ml normal saline
IV mini bottle to run over 20 minutes
The volume set on the infusion control device is the volume of medication to
be administered in one hour. We know from the assignment that we need to
identify how many mls to infuse in one hour so that 50 ml infuses in 20 minutes.
Divide 60 minutes by 20 minutes to calculate how many times the 50 mls will
infuse in one hour. Multiply 50 ml × 3 times. The answer, 150, is the volume per
hour to set on the infusion control pump to have 50 ml infuse in 20 minutes.
17. Calculate the following:
To run over 30 minutes via infusion control device.
What is the rate you should set on the infusion control device?
_________________________________________________________________________
_________________________________________________________________________
b.Assess the insertion site for dislocation, infiltration, or other
complications immediately before administering medication
1)
2)
OR
Assessing the IV site will place you at risk for body fluid pathogen transmission;
therefore, wear gloves when palpating or feeling around any IV site.
Medications
c.
IV.H.4.k
Clears air from the tubing before initiating flow
If necessary, clear air from the tubing before initiating the flow of the medication.
If using a primary-secondary setup, you may use the back flush method to clear
the line. When you are running medication through a line, the CE will provide a
calibrated medication cup to catch the medication being flushed through the line
in order to prevent the loss of medication. When clearing the line of air no more
than 10% of the liquid medication can be lost.
Back flushing is a method used to clear the secondary tubing of air when a
primary/secondary IV setup is used to administer IV medications. To clear air
form the secondary line, lower the secondary bag and tubing below the primary,
open the secondary IV clamp, and allow the primary fluid to flow back into the
secondary line and into the old IV medication bag. Once the line is cleared of air,
clamp the secondary tubing, remove the old IV medication bag, and attach the
new IV medication bag.
d.
1)Aspirates for blood return unless contraindicated
2)Flushes with the designated solution prior to medication
administration
3)Flushes with the designated solution after medication
administration
4)Records the flush solution used on the PCS Response Form
When a medication is to be administered through an intermittent venous access
device (IVAD), assess the site for dislocation, infiltration, or other complication.
Using two (2) separate syringes, flush with the designated solution prior to as
well as after medication administration and record the flush solution used on the
Student PCS Response Form. The designated solution for flushing will be written
on the PCS Assignment Kardex. You may consult the hospital’s policy and
procedure manual or ask the assigned staff nurse any questions regarding the
hospital protocol for flushing intermittent venous access devices.
e.Regulates the flow to deliver the prescribed amount in the
designated period of time (± 5 drops per minute for gravity flow
or the correct ICD setting)
Regulate the flow of a gravity drip to ± 5 drops per minute or set the ICD to the
correct setting. Regulation of flow rate may be required several times during the
PCS for a gravity flow IV since the patient’s position may alter the flow rate of
the medication.
IV.H.4.l
If the IV medication has not completely infused by the end of the Implementation
Phase, you will not be responsible for flushing the tubing after medication
administration. Inform the staff nurse that the medication is still infusing and
that the intermittent venous access device will need to be flushed once the
medication is infused.
Case Study
The patient complains of pain at the IV site as the student flushes
the intermittent venous access device with normal saline prior to
administering IV medication. The student notes that the site is red and
edematous. She tells the CE she is going to hold the medication and
report this to the primary nurse.
10.Records the medications administered on the hospital medication
administration record (MAR) within 30 minutes after administration.
Look at your watch and note the time you administer the medications.
It is recommended that you record on the MAR as soon as possible after
administering the medications. If you bring the MAR to the patient’s room,
sign for the medications administered immediately after verifying the patient
has taken them.
For intravenous medications, complete recording on the hospital medication
record within 30 minutes after intravenous medication has begun infusing.
If the PCS end time comes within 30 minutes of administering the medication,
you will be required to record the medication administration on the MAR before
the end of PCS.
11.Records on the PCS Recording Form data related to condition of
insertion site for peripheral, central, or implanted venous access
devices
Medications
1. What should you do if the patient’s medications are labeled by their generic
names and the MAR lists the trade names?
Reference your drug handbook so that you can look up the medications to confirm
that the generic and trade names match.
Medications
IV.H.4.m
2. What specific nursing actions should you implement prior to giving medications
such as Digoxin, Morphine Sulfate, Insulin or Heparin?
• Digoxin: take an apical pulse. Follow hospital policy regarding
holding the medication.
• Insulin: assess for signs of hypo/hyperglycemia, most recent
glucose level.
• Heparin: assess for bleeding from any body orifice or bruising, and most
recent lab values. Do not aspirate prior to injection.
• Morphine Sulfate: assess pain level, last dose and respiratory rate.
3. What should you do if you have been assigned to give an antihypertensive
medication to your patient and your patient’s blood pressure, when you checked
it, was 90/50? (The patient’s baseline BP was 150/90.)
You would hold the medication and consult with the primary nurse.
4. What laboratory test values should you check before administering diuretics,
digitalis preparations, and anticoagulants?
Check potassium levels for diuretics, digoxin levels for digitalis, partial
thromboplastin time and prothrombin time for anticoagulants.
5. You are to administer Furosemide (Lasix) 20 mg, however 40 mg tablets are
available. How would you prepare to give the correct dose?
Calculate for the correct dose. You would break the pill in half with a pill cutter.
6. Your patient is NPO and is receiving nutrition and hydration through a G-tube.
a.
How would you prepare a tablet for administration via this tube?
dult: Crush well, add 30 mls of warm water to dissolve completely. Flush
A
the tube with water before and after administration with 15–30 mls, or the
designated amount.
hild: Crush well, add 30 mls of warm water to dissolve completely. Flush the
C
tube with water before and after administration with 5–10 mls.
b.How would you prepare a nonsustained action capsule for administration
via this tube?
Open the capsule, mix content into enough water to dissolve the medication.
Irrigate the tube with water before and after administration.
If you are not sure if the medication should be crushed or removed from the
capsule, consult your drug book or the pharmacy at the test site.
IV.H.4.n
7. Not all insulin syringes are marked using the same system of measured
increments for units of insulin. Some syringes are marked by 1-unit increments
and some are marked by 2-unit increments.
How will you be sure you have drawn up the correct dose?
Determine if the syringe is a ½-cc syringe or a 1-cc syringe. There are 100 units in a
1-cc syringe with each marking indicating 2 units. If the syringe is a ½-cc syringe or
a low dose syringe, there are 50 units with each marking indicating 1 unit. Low dose
syringes are commonly used when the total dose is less than 50 units. It is much
easier, especially if the dose is an odd number, to measure the dose using the ½ cc
or 50 unit syringe because the markings indicate only one unit.
8. Suppose you are using a disposable injection unit such as a Tubex or Carpujet
system. These unit dose medications usually contain overfill and air in the
cartridge. How would you handle such a situation in order to measure the
correct dose of injectable medication?
You would expel the air and adjust the dose of the medication, unless
contraindicated.
9. What would you do if you prepared the medications to be administered, walked
in the room and found your patient’s ID band on the floor near the bed?
Ask the clinical examiner to ID patient with staff nurse.
10. How would you identify a disoriented or confused patient who has no
ID band on?
Have primary nurse, clinical examiner, or family identify the patient. Request a
replacement name band from assigned RN.
11. While you are drawing up the medication , you realize you are using the wrong
needle size. What should you do?
Once you have drawn up the medication, change the correct needle size, avoid
contaminating the hub of the syringe.
12. Your assignment is to administer an IV medication by secondary infusion. Your
patient has a primary IV infusing via an ICD. How would you manage the ICD
to deliver the medication at the appropriate rate?
Connect the piggyback tubing to the primary tubing above the ICD pump. Unclamp
the piggyback tubing. Lower the primary IV solution bag below the level of the IV
medication bag. Set the ICD pump to deliver the medication at the ordered rate.
If the pump has the feature of a secondary infusion capability, use the secondary
mode to program the pump.
Medications
IV.H.4.o
13. What would you do if a baby spit out part of the medication dose you
administered?
Report this to the primary nurse.
14. You are assigned to administer Heparin subQ and you understand that the
preferred injection site is the abdomen. When you approach the patient and
expose the abdomen, you find that the abdominal incision and dressing cover
most of the available area for injection. What should you do?
Ask the patient or the primary nurse where they have been giving the medication.
15. You enter patient’s room to give Lovenox 30 mg per order. The patient tells you
she just sneezed and that her nose is now bleeding. You do not see any blood
but she says she can taste blood. How should you proceed?
Take the patient’s blood pressure, inspect her nares for evidence of bleeding,
apply pressure and ice to bridge of nose. Hold dose of Lovenox. Notify patient’s
assigned nurse.
16. Calculate:
To run over 30 minutes
Tubing drop factor = 15 gtt/ml
What is the flow rate that you will regulate when administering this antibiotic?
100 × 15 divided by 30 = 50 drops/min
17. Calculate the following:
To run over 30 minutes via infusion control device.
What is the rate you should set on the infusion control device?
100 × 60 divided by 30 = 200 ml
IV.H.4.p
IV.H.5.a
UNIT IV
Section H.5
Patient Teaching
Critical Elements for Patient Teaching
1. Determines the patient’s readiness to learn by
a.
Assessing the patient’s motivation and ability to learn
b.
OR
Identifying barriers to learning
2. Asks questions to identify the patient’s specific learning need
3. Provides accurate information that is appropriate for and consistent
with the identified learning need of the patient
4. Asks questions to determine the patient’s understanding of the
information presented
5. Records
a.
Assessment of learning readiness
b.
Information provided
c.
Patient response to information provided.
Patient Teaching is the assessment of the need for teaching and provision
of information to meet a patient’s need.
Patient Teaching will be co-assigned with another Area of Care. Hospitalized patients
frequently have learning needs which center around the disease process, methods
of care, types of treatment, and the health care setting. Learning begins with the most
basic concepts and then builds to incorporate more complex information. Patient
interest, ability to learn, and the time available to teach will determine the complexity
of the lesson. For example, acutely ill patients require basic information that enhances
their recovery until they feel well enough to review more complex information about
their condition.
Your brief teaching session during the PCS should be confined to basic concepts
centered around the patient’s disease process, self-care needs, or medical treatments
and should be consistent with the co-assigned Area of Care. You should plan to
spend approximately five to ten minutes teaching your patient. You may use the
unit procedure manual, unit teaching handouts, and drug books as resources as
you develop the teaching session.
IV.H.5.b
Patient Teaching is more than just giving information. Establish a rapport with the
patient to create an atmosphere in which the patient feels free to focus on the topic
and ask question. Assess the patient’s perceived learning needs and abilities so that
you can develop a teaching session that addresses what the patient wants and is able
to learn.
As in the nursing process, teaching a patient involves the use of assessment, analysis,
planning, implementation, and evaluation as a general framework. Thinking about
how the steps of Patient Teaching is similar to the steps of the nursing process may
help you to better understand patient teaching. Consider the chart below:
Nursing Process
Patient Teaching Process
Assessment
Assess the patient’s readiness to learn or learning barriers
as well as learning needs and abilities.
Analysis
Identify information and methods which fit the patient’s needs.
Planning
Develop the teaching plan.
Implementation
Teach the patient.
Evaluation
Ask the patient questions to evaluate the effectiveness
of the teaching plan.
1. Determine the patient’s readiness to learn by
a.
Assessing the patient’s motivation and ability to learn
Desiring more information indicates the patient recognizes the “need to know”
and is motivated to explore new ways of behaving or thinking. Notice if the
patient demonstrates readiness to learn by asking you questions or by saying
that they want more information about their learning needs. Assessment
data includes but is not limited to a patient’s education level, motivation
level (willingness to learn), ability to learn (how the patient best learns),
developmental level, cultural/socioeconomic factors, physical state, emotional
state, and environment. Information can be obtained from the patient, medical
record, and staff, family or significant others. Examples of questions that can
help you determine the patient’s readiness to learn are:
“Is now a good time to talk about your medications?”
“Are you interested in continuing this discussion in more depth?”
“Would you like more information?”
b.
OR
Identifying barriers to learning
Barriers to learning readiness can include visitors, a loud TV, or patient fatigue.
Other barriers include level of pain or discomfort, lack of alertness, and inability
to concentrate. This information can help you to alter your approach to teaching
Patient Teaching
IV.H.5.c
or help you focus the information you will be teaching. A hostile response to
your approach, or the denial of a problem are other examples of barriers to
learning.
1.Your patient is two days s/p appendectomy. It is time for his dressing
change. You have been co-assigned the Area of Care Patient Teaching with
the Area of Care Wound Management. You have been told in report that the
patient will need to learn how to change his own dressing in anticipation
that he will be performing the dressing changes at home.
a.
Why is it important to assess the patient’s readiness to learn?
_________________________________________________________________________
_________________________________________________________________________
b.What questions would you ask to determine his learning needs and
his readiness to learn?
_________________________________________________________________________
_________________________________________________________________________
c.What observations or responses would indicate that the patient was
ready to learn?
_________________________________________________________________________
_________________________________________________________________________
2. Ask questions to identify the patient’s specific learning need
Ask the patient at least one question to identify a specific learning need. Use
open-ended questions to help you collaborate with the patient and bring out
what is important to the patient.
If you ask a question and the patient denies a learning need, you should
explore the area by asking other questions. Explore with the patient and/or
the significant other what information they would like to learn. Ask the patient
if they have any experience with or prior knowledge of the area you are
planning to explore in order to establish a baseline of information on which
to begin the discussion. You may find that an aspect of patient teaching has
been implemented by the nursing staff on your patient care unit and your
patient requires a review or reinforcement of this information. You may use the
information and teaching material available on the unit, if they are applicable to
your assignment.
IV.H.5.d
Case Study
The CE provides you with an Area of Care to teach about: the patient
indicates that they have more of an interest to meet a learning need
in another area. Invoke CDM and teach about that area. If the patient
identifies many learning needs, you only need to address one of those
concerns in your teaching.
Examples of Questions to ask to identify the patient’s specific learning needs:
“What can you tell me about why you are taking this medication.”
“What foods would you avoid while you take this medication?”
“What signs would you look for to know if your wound is healing?”
“What foods should you eat to increase the amount of potassium
in your diet?”
“How will you know it is alright to take your digoxin,
(your heart medication), when you are at home?”
Listed below are examples of patient situations and learning needs.
Patient Situation
Learning Need
Patient preparing to go home with a
postoperative incision.
How to change a dressing.
Newly diagnosed asthmatic who has just
started inhaler use.
How to use inhaler/spacer.
Child admitted for tonsillectomy.
How to use faces pain-rating scale.
Postoperative abdominal surgical patient who
will be getting out of bed for the first time.
How to transfer in and out of bed to support
wound and prevent discomfort.
Child admitted with diarrhea whose parents
will be providing most of his care.
How to assess output (counting diapers, stools,
and episodes of vomiting).
Adult admitted for an initial episode of
untreated chest pain.
When and how frequently to take medication
for chest pain, and potential side effects.
Signs and symptoms of wound infection.
3. Provides accurate information that is appropriate for and consistent
with the identified learning need of the patient
Provide “in the moment” bedside teaching related to a patient’s learning
need that is specific, accurate, and brief. You are not required to provide new
information. Clarifying information that was previously taught to the patient can
provide reinforcement of content.
Before the discussion, briefly outline for yourself what points you will review
or demonstrate to the patient. Consider any age-related constraints such as the
developmental needs of children, the needs of their parents, the ability of the
elderly to retain information in their short-term memory, hear your discussion,
Patient Teaching
IV.H.5.e
read the material , or see your demonstration. The teaching strategy you
choose will depend on the content you are teaching, the resources available,
the learner’s ability to learn, and their learning style. Keep is simple, specific,
and safe (KISSS).
Once you have identified the information you are going to teach the patient,
prepare for the teaching session by evaluating the environment for potential
distractions such as noise. Provide privacy.
4. Ask questions to determine the patient’s understanding of the
information presented
It is important to obtain feedback from the patient and family (if family members
participated in the teaching session). The patient’s responses help you to
determine if he understands the information presented. Ask questions that
encourage the patient to explain what they have learned. You may also provide
the patient with hypothetical situations and ask them what they would do.
The following are examples of statements and questions that determine the
patient’s understanding of the information presented:
“Now that I have reviewed this with you, please show me how you
use the inhaler.”
“Please tell me why you take this medication.”
“What are the warning signs and symptoms of wound infection?”
“Tell me what you would do if you notice green drainage oozing from
your incision.”
“You wake up in the morning and notice your jaw is aching and you
feel chest pressure, what should you do about this?”
2. You are assigned a 5-month-old admitted for diarrhea 2 days ago, the child
will be discharged later in the day. The Area of Care Patient Teaching has
been co-assigned with Enteral Feeding. The baby currently is on ½ strength
formula. What would you teach the mother about formula preparation?
________________________________________________________________________
________________________________________________________________________
5. Records
a.
Assessment of learning readiness
b.
Information provided
c.
Patient response to information provided
IV.H.5.f
Documentation of your patent’s readiness to learn, information presented and
patient response to the information provided will be completed in narrative note
on the PCS Response Form.
Examples of Acceptable recordings:
“I asked the patient if now was a good time to talk about his insulin and he
said it was. I then asked him to tell me what he knew about the new insulin
prescribed for him by his physician. He stated that he had been speaking to his
nurse but couldn’t really remember what she said, except that his insulin was
new to the market. The patient demonstrated a readiness to learn by asking
why he needed the new medication. After providing information about its use,
scheduling, effects and side effect, the only information the patient could restate
was the reason why the medication was prescribed, which was to achieve
better blood sugar control. The patient acknowledged the need to review the
information until he had a ‘grasp of it’.”
“The patient was assessed regarding her understanding of how to take her
medications. I asked her to tell me how and when she used her inhalers.
She stated she only used her bronchodilator inhaler if she was having trouble
breathing and only used her steroid inhaler occasionally. When asked if she
thought this was contributing to her breathing problems, she said that she
knew it was. She agreed to review the indications for use of her steroid and
bronchodilator inhalers and also felt ready to discuss it right away. After the
review the patient was able to explain when she needed to use the inhalers in
the future and demonstrate proper inhaler technique. She said she felt better
after going over the information.”
“I asked the patient questions about how he planned to manage wound care
at home. He said he would be changing his own dressing but was unsure of
how to do it He said that he had been trying to learn by observing the nurses
and thought he could do it with some guidance. I asked the patient if he would
like to begin learning to do this for himself, and he stated “yes.” I demonstrated
the procedure to apply Accuzyme ointment and a dry sterile dressing to the
left lower leg. The patient then repeated the demonstration, needing minimal
coaching about how to apply the ointment and wound cover. The patient said he
would like to dress the wound himself the next time it needed to be changed.”
Below are suggestions for topics to teach the patient or significant other
related to specific Areas of Care.
Fluid Management
• H
ow to assess output; e.g., count number of diapers,
number of stools in 24 hours, episodes of vomiting
• How to measure intake; e.g., ounces of formula, water, etc.
• Positioning for safety related to intake of fluids to prevent aspiration
• Fluid restriction, number of ounces, how to manage over 24 hours
Patient Teaching
IV.H.5.g
Comfort Management/Pain Management
• M
edication
Side effects (constipation, urinary retention, pruritus)
Safety (dosing, storage)
• Positioning
• Use of heat or cold applications
• D
emonstrate methods of relaxation; e.g., visualization,
progressive muscle relaxation
• Administering correct dosage based on child’s growth and development
Medications (choose one (1) assigned medication: one (1) aspect of that medication)
• Compliance enhancers
• Potassium supplement with diuretics
• Importance of completing medication regimen as
in antibiotic prescription
Oxygen Management
• Safety issues associated with oxygen use
• How to properly use equipment; e.g., cannula, face mask
• Oral hygiene measure
• How to balance rest and activity periods
Wound Management
• R
eview needed supplies, procedure for wound care,
how to maintain asepsis
• Wound assessment
• N
utritional needs related to normal healing;
e.g., foods high in vitamin C and protein
• Ostomy site care
• U
se of devices-walkers, canes, crutches, wheelchairs,
elastic stockings (TEDs)
• Cast care, splint care
• Proper body mechanics
• The hazards of immobility
IV.H.5.h
Patient Teaching
1. Your patient is two days s/p appendectomy. It is time for his dressing change.
You want to teach him how to dress his own wound with the expectation that
he will be performing his future dressing changes at home.
a.
Why is it important to assess the patient’s readiness to learn?
If you try to teach the patient when he or she is tired, distracted or in pain,
the patient would be less likely to understand or retain the information
you are sharing.
b.What questions would you ask to determine his learning needs, readiness
to learn, and/or barriers to learning?
• What have you and the nurses been discussing about your wound care?
• Can you describe to me how you would set up your dressing supplies
at home?
• Is this a good time to discuss your dressing changes?
• On a scale of 0 –10, how would you describe your pain right now?
c.What responses would indicate that the patient was ready to learn?
• Responding yes to the question “Is this a good time to discuss your
dressing change?”
• Asking questions
• Actively participating in the discussion
2. You are assigned a 5-month-old admitted for diarrhea 2 days ago; the child will
be discharged later in the day. The Area of Care Patient Teaching has been coassigned with Enteral Feeding. The baby currently is on ½ strength formula.
What would you teach the mother about formula preparation?
Using the patient teaching material available on the unit and after checking with the
assigned nurse to determine what has already been taught, review with the mother
her understanding of how to prepare the formula and reinforce that the formula is
to be made with equal amounts of water and formula. Ask about the water source
at the home (well or community water) and reinforce any instructions that were
previously given about using bottled water or using boiled tap water.
IV.I.1
UNIT IV
Section I
Evaluation Phase
Critical Elements for the Evaluation Phase
1. Communicates nursing care provided by
a.Recording all information required by the Critical Elements for
the assigned Areas of Care on the Student PCS Response Form,
including any observation of the patient’s condition that could
influence subsequent care.
b.Reporting to the assigned staff nurse any change that indicates
an improvement or deterioration in the patient’s clinical condition.
2.Selects one priority nursing diagnosis
a.Writes a related factor for the selected nursing diagnosis
b.Writes the signs and symptoms (defining characteristics)
for the selected nursing diagnosis, if an actual problem
c.
d.Justifies the importance of choosing this as the priority
nursing diagnosis
Writes a measurable outcome
3. Writes an evaluation statement regarding the patient’s progress
toward achievement of the outcome
4. Revises the two interventions for the selected nursing diagnosis,
if necessary
5. Implements the interventions prescribed in the nursing care plan
6. Writes an evaluation statement on the effectiveness of the
nursing interventions
The Evaluation Phase begins with data collection in planning and is an
on-going process throughout the PCS. The nurse continuously reexamines
the assessment data, planning, diagnoses, and implementation of nursing
actions to determine the patient’s progress toward the expected outcomes.
Documentation of data collected and nursing care provided will be accepted
provided the recording and evaluation Critical Elements are met and the
patient’s physical and emotional well being are not jeopardized. The student
is to finalize the NCP as correct and consistent with the patient’s condition,
focusing on the priority patient problem at the time of the PCS.
IV.I.2
1.Communicates nursing care provided by
a.Recording all information required by the Critical Elements for
the assigned Areas of Care on the Student PCS Response Form,
including any observation of the patient’s condition that could
influence subsequent care.
Document all the information required by the recording Critical Elements for
all assigned Areas of Care for each PCS. You will use the Student PCS Response
Form to record all required information. Proper use of objective terminology
is required.
b.Reporting to the assigned staff nurse any change that indicates an
improvement or deterioration in the patient’s clinical condition.
Report to the assigned staff nurse any changes in the patient’s condition which
reflect a difference from the baseline data you were given in report. The timing
of this action is determined by the clinical significance of the change. A sudden
change in the patient’s condition from normal or if the assigned staff nurse
needs to immediately act on a change, is something to report promptly. For
example, any elevation of temperature in the patient who has been afebrile
or an elevated blood pressure from patient’s baseline.
Examples of Changes in the patient’s clinical condition that students should
report at the end of the PCS might include:
• A
n improvement in the patient’s activity level; e.g., the patient is able
to do more self–care activities; the patient is able to ambulate a greater
distance; the patient has increased ROM in a joint
• A
change in the patient’s appetite from what has been previously
recorded
• A patient informs you of a new health status alteration
• A
n observation of a new condition not previously documented in the
patient’s record; e.g., a reddened area on the skin or a previously intact
area that is now open, or a depressed respiratory rate.
Etiology (the related to factor) is the cause of, or a contributing factor causing
the problem (nursing diagnosis). Etiology is never a procedure, treatment or
person. However, the use of a medical diagnosis as the etiology is acceptable.
Evaluation Phase
IV.I.3
b.Writes the signs and symptoms (defining characteristics) for the
selected nursing diagnosis, if an actual problem
The signs and symptoms are the defining characteristics (assessment data)
giving proof that the problem exists.
c.
Writes a measurable outcome
The outcome statement is the benchmark used to evaluate the patient’s progress
in resolving the problem.
d.Justifies the importance of choosing this as the priority
nursing diagnosis
The Evaluation Phase is the time during the PCS to review the Nursing Care Plan
you developed in the Planning Phase of the PCS. After reflecting on the patient’s
condition, the care delivered, and the need to move the patient toward meeting
the identified desired outcome, choose a priority problem (nursing diagnosis)
from the two listed during the Planning Phase. Analyze the data and conclude
which identified nursing diagnosis represents a problem that most impairs
the patient’s health status. Consider the following when ranking the patient’s
problems in order of urgency:
• Maslow’s Hierarchy of Needs
• the need to individualize care
• patient preferences
• the condition under treatment
• the expected patient outcome
If needed, you may write an entirely new nursing diagnosis and address
this as the priority problem. In the Evaluation Phase, an actual nursing
diagnosis (written on the Planning Phase Care Plan) from Carpenito-Moyet or
Ladwig and Ackley can be changed to a risk diagnosis if there is no evidence
that an actual problem exists.
Choose a priority patient problem
Priorities are assigned on the basis of the nurse’s judgment and the patient’s
preference. A reason for choosing a particular nursing diagnosis as a priority
over another may be based on:
• human responses (e.g., separation anxiety in a child)
• physiological changes (e.g., hypotension)
• t reatment related issues (e.g., changes in clinical condition from
what was previously reported)
• environmental hazards (e.g., protecting a confused patient from injury)
• m
aturational considerations (e.g., providing for physical safety
for a hospitalized child)
IV.I.4
Following are examples of patient problems prioritized using Maslow’s Hierarchy
of Needs and related nursing diagnosis.
Maslow Hierarchy of Needs
Possible Nursing Diagnosis
Physiologic
Pain R/T inflammation
Safety and Security
Risk for injury R/T disorientation
Love and Belonging
Social Isolation R/T communicable disease
Self-esteem
Situational Low self-Esteem R/T inability to
act as family breadwinner
Rationale of the importance of choosing the priority nursing diagnosis
Case Study
When choosing between a patient with unrelieved pain and knowledge
deficit regarding discharge planning , the choice would be pain as the
priority. The effect of pain on the patient’s functional status will impact
the patient’s ability to learn.
For example, you might select acute pain as the priority diagnosis because
control of pain reflects a basic need within the Maslow’s Hierarchy of Needs
Framework. A part of your rationale should address what the consequence(s)
might be if the problem is adequately addressed or not adequately addressed.
An example of a rationale for Acute Pain might be written as follows: Control
of pain is a basic human need. If pain control is not adequately managed the
patient may be hesitant to fully participate in the treatment plan, which could lead
to a complication such as pneumonia that might then delay healing and prolong
hospitalization. OR If the pain control is adequately addressed the patient is more
likely to participate in the treatment plan, healing will progress as expected, and the
patient should return to their pre-hospitalization functionality.
Case Study
Turn to The Planning Phase and find the NCP example about 8-yearold Cindy Burns who recently had an appendectomy. The problems
identified in the Planning Phase were Acute Pain and Ineffective Airway
Clearance. Based on the data you collected in the Implementation
Phase, choose one of those problems identified as a priority problem
for this patient. The following sample documentation of data observed
in the Implementation Phase will help you decide which nursing
diagnosis is a priority for this patient. Review the data provided prior to
making your final determination.
Evaluation Phase
IV.I.5
Implementation Data for Cindy Burns
Drainage collection
Abdominal J.P. drain intact draining a small amount of serosanguinous drainage.
Pain Management
Patient pointing to abdomen and crying in pain . Points to the number five
frowning face on the Faces Rating Scale. Assigned staff nurse medicated patient
with ordered Morphine Sulfate. Within 20 minutes the patient rated pain as face
number 2. Able to distract patient with paper and pencil for drawing.
Breath sounds clear on auscultation bilaterally in all lobes prior to respiratory
hygiene activities. Breathing pattern unlabored. Instructed to cough, deep
breathe, and use the incentive spirometer. Patient was able to follow directions
and perform respiratory hygiene activities as directed 20 minutes after being
medicated by assigned staff nurse. Breath sounds remain clear after respiratory
hygiene activities. Breathing pattern unlabored.
Wound Management
Abdominal surgical wound site approximately ½ inch long with J.P. drain in
place. Wound edges reddened, skin surrounding drain slightly reddened, dry,
and intact. Dry sterile dressing applied. Patient offered no complaints during
procedure.
From the preceding data, you conclude that pain control is the most important or
priority diagnosis. With pain control the patient was able to participate effectively
in respiratory hygiene activities and tolerate the dressing change. The rationale
should answer the question, “Why is it important to address this problem?” or
“If I don’t address this problem how is the health status of my patient affected?”.
Nursing Diagnosis
Nursing Diagnostic Label (patient problem)
Acute Pain
Related factor (etiology)
Tissue Trauma
Signs & Symptoms (for actual diagnosis)
reports pain level as 2 on a 0 – 5 faces scale
Rationale for choice as a priority patient problem: Control of pain is a basic human need.
Providing pain relief assists the patient to tolerate dressing changes and participate in
respiratory hygiene activities. The relief of pain allows participation in these activities,
avoids complications such as pneumonia, promotes recovery, and hospital discharge is not
prolonged.
IV.I.6
Completing the nursing diagnosis statement
A complete and acceptable actual nursing diagnosis for an existing problem
includes a diagnostic label, an etiology (related factor) and the signs and
symptoms (defining characteristics)
A complete and acceptable risk nursing diagnosis for a potential problem
includes a diagnostic label and an etiology (rlated factor).
A complete and acceptable risk nursing diagnosis for a potential problem
includes a diagnostic label and an etiology (related factor). Compare the risk
or actual diagnostic statement with the presenting symptoms or condition
of your patient and compare this with defining characteristic in either of the
approved nursing diagnostic books. If your data is consistent, then complete the
Evaluation Phase nursing diagnosis column on the Evaluation Phase Nursing
Care Plan. If your data is not consistent with what you find in either handbook,
then you should consider writing a new nursing diagnosis or altering the nursing
diagnosis written in the Planning Phase. For example, a nursing diagnosis of
“Acute Pain” can be changed to “Risk for Acute Pain” when a patient consistently
rates his or her pain as zero on a 0 –10 pain rating scale.
3.Write an evaluation statement regarding the patient’s progress toward
achievement of the outcome
Evaluation is a measurement of the degree to which patient outcomes are
achieved or met. Evaluation is done primarily to determine whether the patient
is experiencing resolution of the problem. Patient achievement of the expected
outcome provides the basis for evaluating the progress of the patient. In
order for you to effectively evaluate your patient’s care plan, you will need to
synthesize the data obtained from your observations of and communications
with your patient. Write a statement on the Evaluation Phase NCP page in the
designated area which describes the patient’s progress toward or away from
the achievement of the identified outcome.
Writing an Evaluation Statement
For each expected outcome:
1.Write the patient’s response to the nursing interventions implemented.
Indicate any change in patient condition since the implementation of
nursing care.
2.
Compare the patient’s response to the expected outcome.
Evaluation Phase
IV.I.7
3.Evaluate if the expected outcome was met, partially met or not met. If the
patient’s response was what you expected, then the outcome was met.
The outcome was not met if the patient’s condition related to that problem
is the same. The outcome may be partially met if the expected outcome
was not achieved but the patient’s condition is improving.
Case Study
Reflect on 8-year-old Cindy Burns’ Planning Phase NCP example. For
the priority problem chosen, Acute Pain, an evaluation statement may
be developed and written as follows:
Outcome
Observed Patient Behavior
The patient will report pain
< 3 on 0-10 scale
Patient reported pain level
of 1 on 0-10 scale within
30 minutes after pain relief
measures implemented.
Evidence of Progress toward
Achievement of Outcome
√ M
et, patient reported
c
a decrease in pain to
a 1 on a scale of 0 –10.
1.
Write an evaluation statement for the following examples.
Nursing Diagnosis
Acute Pain
Impaired Mobility
Anxiety
Measurable
Expected Patient
Outcome
Observed Patient
Behavior
Evidence of Progress
toward Achievement
of Outcome
c
Met
c
Partially met
c
Not met
The patient will
ambulate to nurses’
station one time.
The patient ambulated
to room door, patient
complained of being
dizzy.
c
Met
c
Partially met
c
Not met
The patient will
verbalize decreased
anxiety.
The patient stated
“I am over-whelmed,
I don’t know what
to do.”
c
Met
c
Partially met
c
Not met
The patient rated the
The patient will rate
pain between 0–1 on
pain < 3 on 0–10 scale.
0–10 scale.
4. Revises the two interventions for the selected nursing diagnosis,
if necessary
During Implementation you might have discovered that an intervention you
performed was not effective in moving the patient toward the expected outcome
and you performed another intervention that did move the patient toward the
expected outcome. This new intervention would replace an intervention from
IV.I.8
you Planning Phase NCP. Write the revised (newly implemented) intervention(s)
on the Evaluation Phase NCP prior to submitting your completed PCS response
form to the CE.
5. Implements the interventions prescribed in the nursing care plan
6. Writes an evaluation statement on the effectiveness of the
nursing interventions
You are expected to implement the interventions prescribed in the Nursing
Care Plan. If unable to carry out the intervention written on the Nursing
Care Plan you will be required to suggest an alternative intervention on the
Evaluation NCP.
Under each intervention on the Evaluation Phase care plan identify
one statement which indicates if the intervention you performed in the
Implementation Phase was either effective, not effective or if you were
not able to carry out the intervention.
Validate an “effective” evaluation of the intervention by documenting the
patient’s response to the nursing intervention you performed during the
Implementation Phase. We recommend that during the PCS you note the
patient’s verbal and nonverbal responses related to each intervention you
perform. The patient’s responses provide evidence supporting an “effective
intervention” decision. The statement must be the patient response you
observed or the assessment data you collected. The responses would be
considered as you make a decision regarding the patient’s achievement of the
outcome. Do not write a rationale for the intervention; this will result in failure
of the PCS.
If your intervention is marked “not effective,” suggest an alternative
intervention. You are not required to perform the alternative intervention.
Continuing an existing intervention is an acceptable alternative if continuing the
intervention is likely to move the patient toward achievement of the outcome.
During the Evaluation Phase you will have the benefit of having worked with the
patient. Information about the patient’s abilities, motivation and needs will guide
you when you need to suggest an alternative intervention or allow more time for
the intervention you have implemented to be effective in achieving the desired
outcome. If you were “unable to carry out the intervention” you need to state
why this was the case. An example of this might be the patient refuses the fluids
you plan to encourage due to nausea or prefers not to ambulate due to fatigue.
Case Study
The interventions implemented for Planning Phase examples of Cindy
Burns included offering paper and pencil as distraction and asking the
assigned staff nurse to administer the pain medication. Based on the
student’s documentation, we already concluded the patient’s outcome
was met.
Evaluation Phase
IV.I.9
Example of Acceptable Recording
Priority Diagnosis: Acute Pain R/T tissue trauma as evidence by patient
complaints and grimacing
Nursing Intervention #1
1.Offer distraction technique of
paper and pencil.
Nursing Intervention #2
2.Ask assigned staff nurse to administer
pain medication as needed.
Evaluation of effectiveness of nursing
intervention in moving patient toward
achievement of patient outcome
Evaluation of effectiveness of nursing
intervention in moving patient toward
achievement of patient outcome
c
√ Effective; describe patient’s response
√ Effective; describe patient’s response
c
Patient quietly drew pictures. Rated pain as 1
on the 0–5 faces rating scale.
Patient rated pain on 0-5 faces scale as 1,
30 minutes after being medicated
c Not effective; suggest an alternative
c Not effective; suggest an alternative
intervention
c Unable to carry out and why?
intervention
c Unable to carry out and why?
2.The sample Planning Phase NCPs are presented on the following pages with
the information gained in the Implementation Phase. The Implementation
Phase information is found on the PCS Recording Form page of the Student
PCS Response Form and the Narrative Nurses’ Notes pages. This data will
help you evaluate your plan of care and develop an Evaluation Phase Care
Plan. Practice changing and modifying each care plan before checking your
answer against our sample responses.
IV.I.10
1
0730
Jean Kaffman
802
10/19/58
Lortab 5 mg for pain
Has a weak cough
√
x2
√
Tameka James
o known
n
allergies
eye
glasses
√
1000
Degenerative Joint Disease
Post op day #2
2 days ago
Right total knee replacement
Female
127650
*
√
√
√
*
oral
digital
√
√
√
D5 LR
√
75 ml/hr
√
10 gtt/ml
√
√
report to assigned
nurse if
< 92%
√
√
with one assist
√
√
walker; weight bearing as
tolerated
√
√
√
√
TED stockings
Regular
√
√
√
**
Incentive
**
√
√
**
0830 L
ovenox 30 mg Subq
0830 Multivitamin ÷ tab PO
√
√
**
right leg
CPM; flexion
10-45 °; extension 0-10°; 10 cycles/
min while in bed
√
ice bag
continuously to right knee
Evaluation Phase
Critical Thinking Answer Key #10:
PCS #1 Jean Kaffman
Instruct patient to cough forcefully
Ineffective airway clearance [R/T
retained secretions AEB abnormal
have clear breath sounds after
breath sounds]
respiratory hygiene activities.
after 3 deep breaths
Phase.
Impaired physical mobility
[R/T tissue trauma AEB need for
assistance getting OOB]
IV.I.11
Assess strength of lower extremities
express feelings of increased strength
Assist patient with use of walker
when getting OOB.
Phase.
12 gtt/min
IV.I.12
Evaluation Phase
IV.I.13
PCS #1 Jean Kaffman
0900 orange juice 120 ml
tea
240 ml
0930 urine 150 ml
prolonged tenting
D5 L.R.
redness, warmth,
coolness absent
992
100
99
28
28
CPM machine maintained
while in bed. Assisted
OOB to chair using walker
and one assist.
Uneven gait with minimal
weight bearing to right leg.
Patient c/o being tired after
transferring to chair.
132/70 130/70
98%
2
IV.I.14
Narrative Nurses’ Notes
Document the pertinent patient data including all related assessment findings for
Assigned Areas of Care not included on previous page of the PCS Recording Form.
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Comfort Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Irrigation
_ __________________________________________________________________________________
_ __________________________________________________________________________________
CPM machine functioning at prescribed setting of right knee flexion
_ __________________________________________________________________________________
10–45 degrees and extension 0–10 degrees, 2–10 cycles/minute
_ __________________________________________________________________________________
while in bed. Right knee joint slightly edematous; ice bag applied
to knee continuously. Staples noted across right knee, otherwise no
_ __________________________________________________________________________________
abnormalities noted. Pt. offers no complaints of pain with prescribed
_ __________________________________________________________________________________
CPM flexion and extension of right knee. Pt. stated “ice to knee helps,
but my knee gets to be too cold sometimes.”
_ __________________________________________________________________________________
Evaluation Phase
IV.I.15
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Oxygen Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Pain Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Patient Teaching
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
pulses strong bilaterally. Toe capillary refill < 3 seconds
_Pedal
__________________________________________________________________________________
bilaterally. Both feet warm to touch. Patient able to wiggle all toes with
ease upon command and can identify, with eyes closed, areas touched
_ __________________________________________________________________________________
on toes of both feet by stating “that tickles.”
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
IV.I.16
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
sounds prior to deep breathing and coughing were clear in upper
_Lung
__________________________________________________________________________________
lobes bilaterally and abnormal in lower lobes bilaterally. Breathing
_posterior
__________________________________________________________________________________
pattern unlabored. Deep breathing and coughing performed per directions.
Cough strong, but non productive. Attempted to instruct patient about
_ __________________________________________________________________________________
incentive spirometer — Patient stated she didn’t need instruction and
_ __________________________________________________________________________________
_ __________________________________________________________________________________
roceeded to perform 10 repetitions of treatment. Lung sounds post
_ __________________________________________________________________________________
treatments remain abnormal in right lower lobe and clear left lower lobe; upper
_ __________________________________________________________________________________
lobes remain clear bilaterally. Patient c/o of being tired after treatment; no
_ __________________________________________________________________________________
dyspnea noted. Breathing pattern remains even and un-labored.
Skin Assessment
Pressure Ulcer Risk Assessment Score ___________
___________ Risk
___________ No Risk
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Wound Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Evaluation Phase
IV.I.17
Other Observations
taken as offered and tolerated by patient.
_Fluids
__________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
IV.I.18
2
1100
Will O’Brien
5432
3/6/39
has triple lumen catheter
Receiving IV antibiotics; has oral thrush,
c/o poor nights sleep
√
x2
1330
Left lower lobe Pneumonia, COPD
2 days ago
Male
678910
Nadine
√
Cleocin
√
*
√
√
eye glasses
√
*
√
oral
digital
√
D5 W –c
20 meq
Potassium Chloride
125 ml/hr
√
√
√
√
√
√
√
self
X 1 during PCS
√
√
√
Regular
√
√
√
**
Incentive
**
Beclovent Multidose Inhaler
2 puffs
1200
Atrovent Multidose Inhaler
2 puffs
1200
Nystatin 100,000 units (1 ml) po
swish and swallow 1200
√
√
√
**
2 liters/min
report to
nurse if 92% or less
**
medications
Evaluation Phase
IV.I.19
Altered oral mucous membranes
[R/T oral thrush AEB cracked
tongue]
demonstrate techniques to restore
integrity of oral mucosa
Teach patient to rinse mouth post
inhaler use
Instruct patient to swish Nystatin
around mouth and then keep in
mouth as long as possible before
swallowing
Sleep disturbance [R/T frequent
awakening. AEB complaints of
report feeling less tired
Organize care to allow patient
to nap after lunch
feeling tired.]
Elicit the patient’s preferences in the
organization of care
IV.I.20
Evaluation Phase
IV.I.21
juice 120 ml
tea 240 ml
H20 120 ml
Nystatin 1 ml
tongue cracked,
white coating present, “sore”
none
_
D5W c 20 meq
Potassium Chloride
125 ml / hr
slightly cool
992
992
90
92
18
19
130/80
130/78
Refused to get OOB to
chair due to tiredness and
had just returned from
chair 30 minutes earlier.
Repositioned in bed with
assistance in preparation
for lunch. No dyspnea noted
during repositioning
activities.
——
95%
95%
1
1
IV.I.22
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Comfort Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Irrigation
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Evaluation Phase
IV.I.23
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Oxygen Management
No shortness of breath noted while repositioning in bed. Oxygen
_ __________________________________________________________________________________
saturation 95%, clubbing of finger nails noted. Oxygen @ 2 L via
_ __________________________________________________________________________________
nasal cannula. Denies soreness of nares or ear area where tubing rests,
no skin irritation noted. Patient states “his breathing is fine” but the
_ __________________________________________________________________________________
coughing and secretions he is expectorating are keeping him from
_ __________________________________________________________________________________
sleeping well.
_ __________________________________________________________________________________
Pain Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Patient indicated readiness to learn by expressing interest in
medication
effects
on oral discomfort. Inhaler medications reviewed with patient
_ __________________________________________________________________________________
(actions, sequences of inhaling). Expressed willingness to discuss medication and
_ __________________________________________________________________________________
demonstrated use of devices in proper sequence and using proper technique. Is not
mouth after corticosteroid inhaler. Instructed patient regarding this and
_rinsing
__________________________________________________________________________________
immediately performed. Nystatin provided; patient knew why he was using
_patient
__________________________________________________________________________________
medication but did not realize he was not to swallow immediately after swishing
_ __________________________________________________________________________________
but to keep in mouth as long as possible. When Nystatin administered patient
_ __________________________________________________________________________________
demonstrated understanding of teaching by swishing medication in mouth for a
_length
__________________________________________________________________________________
of time before swallowing.
Patient Teaching
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
IV.I.24
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Abnormal breath sounds noted in posterier upper and lower lobes
_ __________________________________________________________________________________
bilaterally. Breathing pattern even without dyspnea. Pt coughed
_ __________________________________________________________________________________
forcefully after three deep breaths. Small amount of frothy yellow/white
_ __________________________________________________________________________________
sputum produced. Five repetitions of Incentive Spirometer performed.
_ __________________________________________________________________________________
Reassessment: Posterior lung sounds remain abnormal lower lobes
_ __________________________________________________________________________________
bilaterally; upper lobes clear bilaterally. Breathing pattern remains even
_ __________________________________________________________________________________
and unlabored. Patient tolerated respiratory hygiene activities without
_ __________________________________________________________________________________
complaints.
_ __________________________________________________________________________________
Skin Assessment
___________ Risk
___________ No Risk
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Wound Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Evaluation Phase
IV.I.25
Other Observations
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
IV.I.26
3
1000
Ruptured Appendix
3 days ago
Appendectomy
POD #3
John
0730
Carlos Lopez
Female
510A
1/6/2000
123456
Tylenol –c codeine ordered for pain.
√
x2
√
o known
n
allergies
*
√
√
√
√
3 days ago
*
temporal
√
D5 ½ NS
–c 20 meq
Potassium Chloride
80 ml/hr
√
15 gtt/ml
√
√
√
√
√
√
√
√
with one person x1 during PCS
√
√
**
clear liquids
√
√
√
**
Incentive
**
√
wet to moist
NormalSaline drsg,
pack surgical
incision cover
with DSD
**
Ampicillin 450 mg in
50 ml D5W
√
15 gtt/ml
Evaluation Phase
IV.I.27
Teach patient to splint abdomen
Acute Pain [R/T tissue trauma
demonstrate ways to decrease
AEB grimacing with movement]
discomfort when moving
Reposition patient
Phase.
Anxiety [R/T hospitalization
experience AEB restlessness]
demonstrate less restlessness
Ask questions to elicit expression
of feelings about hospitalization
Provide distraction activities with age
appropriate games.
Phase.
20
IV.I.28
Evaluation Phase
IV.I.29
PCS #3 Carlos lopez
ginger ale
100 ml
moist
50 ml IVMB
250 ml urine
D5 ½ normal
_
saline c 20 meq Potassium
Chloride
0 warmth or coolness
25 gtts/min
none
101
101
100
101
24
24
98/64
98/64
During ambulation to
bathroom with mother,
patient required minimal
assistance; gait steady
and posture upright.
Stated “stomach hurt”
when getting OOB;
assisted back to bed, resting.
98%
5
IV.I.30
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Comfort Management
restless; when asked, states he is uncomfortable. Skin is slightly
_Pt
__________________________________________________________________________________
Assisted with washing face and hands. Cool wash cloth
_diaphoretic.
__________________________________________________________________________________
applied to forehead for comfort. Repositioned, head of bed elevated and
incision splinted. Less restlessness noted after comfort measures
_ __________________________________________________________________________________
implemented.
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Irrigation
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Evaluation Phase
IV.I.31
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Oxygen Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Pain Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Patient Teaching
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
IV.I.32
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
sounds clear in posterior upper and lower lobes bilaterally.
_Lung
__________________________________________________________________________________
pattern unlabored. Able to deep breath with weak cough using
_Breathing
__________________________________________________________________________________
as abdominal splint. States it “hurts too much” to cough. Lungs
_pillow
__________________________________________________________________________________
remain clear in upper and lower lobes bilaterally. Breathing
_reassessed;
__________________________________________________________________________________
remains unlabored. Patient rated pain as 5/10; pain level
_pattern
__________________________________________________________________________________
to RN.
_reported
__________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Skin Assessment
___________ Risk
___________ No Risk
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Wound Management
Medicated by RN prior to dressing change. Wet to moist normal saline
_ __________________________________________________________________________________
dressing packed into surgical wound. Skin around incision is red.
_ __________________________________________________________________________________
No wound drainage noted. Wound is located in the lower right quadrant
_ __________________________________________________________________________________
of abdomen. Patient tolerated dressing change without complaint.
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Evaluation Phase
IV.I.33
Other Observations
Body temperature elevated to 101 degrees. Informed assigned nurse.
_ __________________________________________________________________________________
Physician to be notified. Patient stated he was chilled, skin feels warm.
Other vital signs remain within patient range.
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
IV.I.34
Evaluation Phase
1.
Nursing Diagnosis
Acute Pain
Impaired Mobility
Anxiety
Measurable Expected
Patient Outcome
Observed Patient
Behavior
The patient rated the
The patient will rate
pain between 0–1 on
pain < 3 on 0–10 scale.
0–10 scale.
The patient will
ambulate to nurses’
station one time.
The patient will
verbalize decreased
anxiety.
Evidence of Progress
toward Achievement
of Outcome
c
√ M
et. Evaluation
statement: Patient
verbalized a pain
rating of 0 –1.
The patient ambulated
to room door, patient
complained of being
dizzy.
c
√ P
artially Met.
Evaluation statement: Patient able
to ambulate only
to the door then
complained of
being dizzy.
The patient stated
“I am over-whelmed,
I don’t know what
to do.”
c
√ U
nmet.
Evaluation statement: Patient
states he feels
overwhelmed by
his situation, verbalizing he does
not know what
to do.
2. See Evaluation NCP
Evaluation Phase
IV.I.35
PCS #1 Jean Kaffman
Ineffective airway clearance
have clear breath sounds
after respiratory hygiene
Instruct patient to use
Instruct patient to cough
forcefully after 3 deep
Incentive Spirometer
x 10 repetitions
breaths.
activities
retained secretions
Abnormal breath sounds
√
Breath sounds of patient are
clear left lower lobe; remain
abnormal right lower lobe.
√
Patient able to cough
forcefully after 3 deep
breaths; breath sounds
improved
√
Pt. able to complete 10
repetitions of Incentive
Spirometer without dyspnea.
Breath sounds improved.
lower lobes bilaterally
Adequate airway clearance is a basic human need.
Assisting the patient to maintain airway clearance avoids
complications such as atelectasis and allows the patient to
fully participate in the post-operative treatment plan that
promotes healing and avoids prolonged hospitalization.
impaired oral mucous
membranes
thrush
cracked tongue
demonstrate techniques to
restore integrity of
oral mucosa
Instruct patient to swish
Nystatin around in
mouth, keeping in mouth
as long as possible before
swallowing.
Teach patient to rinse
mouth post inhaler use
√
Patient able to demonstrate
proper post inhaler mouth
rinsing and Nystatin
ingestion.
√
Pt. stated he will now rinse
mouth consistently because
he understands why it is
important
√
Pt. demonstrated proper
technique for taking
Nystatin; stated he
understands why.
It is important to have an intact oral mucosa in order to eat
and sustain life. A patient with intact oral mucosa will be
able to consume adequate calories to both sustain life and
provide necessary calories required for healing.
IV.I.36
PCS #3 Carlos Lopez
acute pain
demonstrate ways to
decrease discomfort when
moving
tissue trauma
grimacing with movement
Teach patient to splint
abdomen
Reposition patient
√
√
Pt. able to splint abdomen
with pillow independently;
Pt. splinted abdomen; stated
states discomfort is
it helped, but did not stop the
decreased.
pain completely.
√
Pt. remained uncomfortable
after changing position. Ask
RN to medicate the patient
with Tylenol and codeine.
Being pain free is important to all people. Unrelieved pain
will interfere with mobility and can put patient at risk
for post-operative complications, such as abnormal breath
sounds or decreased bowel motility. Occurances such as
these could alter the patient level of wellness.
IV.J
UNIT IV
Section J
The Simulation Laboratory Stations include:
Section A: Wound Management
Section B: Intravenous Medications
Section C: IV Push
Section D: IM/SubQ Injectable Station
You will be allowed to complete each station without interruption unless evidence
of incorrect performance will be lost by subsequent actions.
Sign your signature at the bottom of the MAR, using the initials ECSN (Excelsior College
Student Nurse) to designate your title.
A sample of the Simulation Laboratory Report is located in Appendix G. A copy of the
Simulation Laboratory Student Orientation Guide is located in Appendix F.
Although the overriding Area of Care asepsis applies to all simulation laboratory stations,
hand washing is not required. If you have a known or suspected latex allergy, contact
a CPNE faculty member to make arrangements for the use of latex free clean and sterile
gloves during CPNE.
IV.J.1.a
UNIT IV
Section J.1
Wound Management
Critical Elements for Wound Management
1. Complies with established guidelines related to managing a wound
2. Removes the dressing without contaminating the wound
3. Disposes of the dressing in the designated container
4. Prepares gauze for application to wound bed
5. Packs wound by applying moist dressing to wound bed
6. Applies a sterile dressing without contaminating the wound
7. Secures the dressing
8. Maintains asepsis
9. Labels the dressing with the date, time, and their initials
10. Completes all the Critical Elements within 15 minutes.
IV.J.1.b
1. Complies with established guidelines related to managing a wound
The sterile inner wrapper of the supplies is a sufficient sterile field.
It is acceptable to wear clean gloves when removing the soiled dressing.
For the laboratory portion of the examination, a waste paper basket will serve as
the designated container for disposal of the dressing.
Wearing sterile gloves, apply a wet to moist sterile dressing to the wound bed on
the mannequin. In preparing the moist sterile dressing for wound packing, the
wet sterile 4×4 gauze needs to be unfolded to create a loose packing that will
cover the wound bed (see pictures).
5. Packs wound by applying moist dressing to wound bed
When packing the wound and applying the sterile dressing, be sure the wet
gauze does not come in contact with the intact skin. If dressing material has
both an absorbent and a waterproof side such as an abdominal pad, be sure
that the absorbent side faces the wound.
The following is a series of photos of packed wounds. It is indicated if the wound
is packed correctly or incorrectly.
6. Applies a sterile dressing without contaminating the wound
Be sure to select the correct glove size to fit your hands securely, if your gloves
are too long they can touch skin surfaces and become contaminated.
It is not necessary to tape the dressing on all sides; however, you will need to
tape the dressing securely. It is acceptable to precut the tape as you are setting
up for the dressing change.
Wound Protection
IV.J.1.c
Correct
Incorrect
IV.J.1.d
Incorrect
Incorrect
Wound Protection
IV.J.1.e
8. Maintains Asepsis
Open the dressing packages using a technique whereby the dressing materials
will remain sterile. Practice putting on the sterile gloves without contaminating
them. Any portion of a sterile glove that is contaminated renders the entire glove
unsterile; therefore, the glove must be changed prior to continuing with the
procedure. If you need to obtain extra supplies from the clean area, remember
that you may not return to the designated clean area wearing contaminated
gloves, e.g., gloves that have come into contact with the patient (mannequin).
9. Labels the dressing with the date, time, and your initials
10.Completes all the Critical Elements within 15 minutes
You are to complete all the Critical Elements for this station within 15 minutes.
When you have completed all the Critical Elements, you may turn to the CE
and say so. The CE will ask the station-ending statement, “Have you completed
all Critical Elements for this station?” When you answer “yes,” your time at the
station will end and the CE will evaluate your performance.
IV.J.1.f
Excelsior College Treatment Record
Treatment Record
Date
Time
Initial
1800
Apply a wet to moist saline gauze
dressing to the mannequin’s wound
1800
1800
1800
1800
1800
1800
1800
KD
SAMPLE
Signature Record
Signature
Initials
Kathie Doyle
Signature
Initials
KD
“Patient’s Name”
Patient Name: _________________________ Diagnosis: ____________________________
12/15/58
078563321
Date of Birth: __________________________ Med Record Number#: ________________
No Known Allergies
Allergies: ______________________________
Wound Protection
IV.J.1.g
1.When donning your sterile gloves you think you may have touched part
of a glove with your ungloved hand. What should you do?
_________________________________________________________________________
_________________________________________________________________________
2.You decide to use a sterile barrier as a sterile field. You touch the outer
edge of the field with your thumb. What action is appropriate?
_________________________________________________________________________
_________________________________________________________________________
3.You finish packing a wound and the packing material is in contact
with the skin outside of the wound bed. Is this correct technique?
If not, describe the correct placement of the packing material.
_________________________________________________________________________
_________________________________________________________________________
4.Does it matter which side of an ABD pad is placed next to the 4 × 4 and
the moist, packed wound? If so, which side should be placed next to
the wound?
_________________________________________________________________________
_________________________________________________________________________
IV.J.1.h
Station A: Wound Protection Station
1. When donning your sterile gloves you are concerned that you may have
touched part of a glove with your ungloved hand. What should you do?
Dispose of the contaminated gloves and begin again.
2. You decide to use a sterile barrier as a sterile field. You touch the outer edge
of the field with your thumb. What action is appropriate?
Remember the outer edge of the field is considered unsterile (the 1-inch border
can be handled without gloves). You can continue to use the barrier.
3. You finish packing a wound and the packing material is in contact with the skin
outside of the wound bed. Is this correct technique? If not, describe the correct
placement of the packing material.
No this is not correct technique. The first assessment required for correctly packing
a wound is to know the size, depth and shape of the wound. The moist gauze
dressing is unfolded to a single layer. Apply the single layer gauze directly onto the
wound surfaces. To prevent maceration of the surrounding skin, pack only to the
edge of the wound, without overlapping onto the skin.
4. Does it matter which side of an ABD pad is placed next to the 4 × 4 and a
draining wound? If so which side should be placed next to the wound?
Yes, it matters because one side of an ABD pad is absorbent and the other side is
waterproof. The plain side (without stripe) is the absorbent side and needs to be
placed next to the wound.
IV.J.2.a
UNIT IV
Section J.2
Intravenous Medication
Critical Elements for Intravenous Medications
1. Complies with the established guidelines related to
medication administration.
2. Selects the prescribed medication using the medication
administration record.
a.
Patient name
b.
Date of birth
c.
4. Uses the prescribed route and/or site for administering the medication
6. When an IV medication is to be administered by the secondary method:
a.Records the correct flow rate in drops per minute on the
Simulation Laboratory Recording Form before administering the
medication
b.Assesses the insertion site for dislocation, infiltration, or other
1)Feeling the surrounding skin for changes in temperature
OR
c.
Clears air form the tubing before initiating flow
d.Regulates the flow to deliver the prescribed amount in the
designated period of time ( ± 5 drops/ minute)
7. Records the medication administered on the medication
9. Completes all Critical Elements within 20 minutes
IV.J.2.b
You will find the medication administration records (MAR) and the medications you
are to administer on the table at the IV medication station. All of the IV medications
are in an IV mini bag (IVMB). In various parts of the USA, an IV minibag medication is
referred to as a piggyback medication. The MAR specifies the IV medication order as
well as the drop factor for the tubing. You will need to calculate and record the flow
rate in drops per minute before administering the IV medication.
An elbow (arm) model will be your simulated patient. The IV site on this model
is checked before initiating the flow of the IV medication. A glove is worn when
checking this site.
Prepare the medication, administer it to the patient (model), and record the
medication administered on the MAR. A patient’s identification (ID) bracelet will
be located on the model. You are to identify this “patient” immediately before
administering the medication.
A primary/secondary IV tubing set will be used at this station. The IV tubing will
be hanging and primed. You will not need to change any of the IV tubing unless
you contaminate it. At the beginning of this station you will find both the primary
and secondary bags hanging at the same level. The primary IV will be infusing, the
clamp on the secondary IVMB tubing will be closed. The purpose of the clamp on the
secondary tubing is to open and close this line.
Open the clamp on the secondary tubing and regulate the flow rate using the roller
clamp on the primary tubing. The IVMB will then flow and the primary IV will stop
infusing. To minimize changes in flow rate, you will find the IV tubing is taped to the
table to prevent dependent loops.
1. Complies with the established guidelines related to
An example of established guidelines related to IVMB infusion includes lowering
the primary IV on a hook to facilitate infusion of the secondary IV minibag and
regulating the IVMB flow rate with the primary tubing roller clamp.
Champagne size bubbles in the IV tubing are acceptable. However, any air that
creates a break in fluid within the IV tubing should be removed.
2. Selects the prescribed medication using the medication
Select the prescribed medication using the medication administration record
(MAR) provided. The physician’s order will be clearly written on the MAR.
IV.J.2.c
Excelsior College Medication Administration Record (MAR)
Dates Administered
Medication-DosageFrequency Route of ADM
Polycillin 2 gms IV q 8 hour in
50 ml Normal Saline Mini Bag
6/13
6/14
0600
LB
ML
1400
ML
2200
FJ
Tubing drop factor = 10 gtts/ml
Give 1400 dose (2 pm)
Signature Record
Signature
Initials
Joan Buono, ECSN
JB
Fred Juarez, ECSN
FJ
Maureen Lrouse, ECSN
ML
GI Bleed
Patient Name: ______________________________
Diagnosis: ____________________________
75438
12/15/58
Date of Birth: _______________________________
Med Record Number#: ________________
No Known Allergies
Allergies: ___________________________________
IV.J.2.d
a.
Patient name
b.
Date of birth
c.
Identify the patient immediately prior to administering the medication using an
ID band attached to the model. This essential behavior supports safe patient
care. Compare the information on the MAR to the ID band. Both the MAR and
the ID band will be marked with the patient’s name, date of birth, and medical
record number. Deliberately perform this action so the CE will see you perform
this Critical Element.
6. When an IV medication is to be administered by the secondary method:
a.Records the correct flow rate in drops per minute before
administering the medication
You will be given a Simulation Laboratory Recording Form for calculating and
recording the correct flow rate. You may use a calculator to compute the flow
rate. Review the flow rate formula in the Area of Care Medication.
IV.J.2.e
Clinical Performance in Nursing Examination
(CPNE)
Nursing Simulation Laboratory Recording Form
Name: _ __________________________________________________________
Social Security Number: __________________________________________
Station B: Intravenous Medication
IV Medication
Gtts/min. _ ______________________________
Use Space Below for Calculations
IV.J.2.f
OR
Assess the IV site for dislocation, infiltration or other complications immediately
before administering the medication. Deliberately perform this action so that the
CE will see you do it. Be sure to wear gloves as you palpate the IV site.
c.
Clears air from tubing before initiating flow
At the IV medication station you will find the primary and secondary tubing free
of air. Although the tubing is already primed for you in the simulation laboratory
setting, you are to prime IV tubing if necessary in the PCSs. Should you introduce
air when spiking the IVMB or by some other means, a strategy to remove the
air would be to lower the secondary IVMB with the roller clamp wide open.
Hold the IVMB below the primary IV to back flush the air into the IVMB. (Look
in Fluid Management for directions on backflushing technique.) If you choose
to disconnect the secondary IV tubing from the primary tubing to expel air, be
prepared to maintain the sterility of the IV connection between the primary and
the secondary tubing.
designated period of time (± 5 drops/minute)
Regulate the flow of gravity drip IV to within plus or minus 5 drops of the drop
rate calculated. After you have regulated your flow rate correctly, take your hand
off the roller clamp and allow the tubing to hang free, then count the rate again
for a full minute. Let your CE know when you are ready to have the IV flow
rate verified.
7.Records the medication administration on the medication
Initial the MAR in the appropriate box designating that you administered
the medication.
IV.J.2.g
8. Maintains Asepsis
The Overriding Area of Care of Asepsis is in effect throughout the administration
of the IV medication. Consider how the principles of medical and surgical asepsis
apply to the Critical Elements of this station. For example, the spike on the IV
tubing is sterile. Maintain sterility of the spike when removing it from the already
infused IVMB and while spiking the new IVMB.
For the Simulation Laboratory, you will be expected to perform all the Critical
Elements for Intravenous Medications within 20 minutes. Practice so that you
feel very comfortable handling the equipment and can complete the Critical
Elements within 20 minutes.
1.How do you apply principles of Standard Precautions when assessing
the IV site?
2.
Ancef 16 mg in 50 ml D5W to infuse in 30 minutes
Drop factor = 15 gtts/ml.
Erythromycin 500 mg in 100 ml normal saline to infuse over 20 minutes
3.
4.You are to administer Keflin 1 Gm in 50 ml Normal Saline over 45 minutes.
The drop factor for the tubing is 10 gtts/ml. Your calculation is 16–17
gtts/min.
Calculate correct drop rate for the following medication orders:
Is this calculation correct?
5.While hanging your IV mini bag you touch the spike to the outside of the
mini bag. What should you do?
6.How do the principles of gravity influence the flow of the primary and
secondary IV solutions?
7.When verifying the IV medication flow rate, what is the advantage of
counting for a full minute versus half or 15 seconds?
IV.J.2.h
Station B: Intravenous Medication Station
1.How do you apply principles of Standard Precautions when assessing the IV site?
You should wear a glove when touching the IV site because there is the danger of
coming in contact with blood and/or body secretions.
2. Calculate correct drop rates for the following medication orders:
Ancef 16 mg in 50 ml D5W to infuse in 30 minutes.
25 gtts/min.
3. Erythromycin 500 mg in 100 ml normal saline to infuse over 20 minutes.
50 gtts/min
4. You are to administer Keflin 1 Gm in 50 ml Normal Saline over 45 minutes.
The drop factor for the tubing is 10 gtts/ml. Your calculation is 16–17 gtts/min.
Is this calculation correct?
No. The correct drip rate is 11 gtts/min.
5. While hanging your IV mini bag you touch the spike to the outside of the
mini bag. What should you do?
Acknowledge that contamination has occurred. Ask for new tubing.
6. How do the principles of gravity influence the flow of the primary and secondary
IV solutions?
When you hang the primary bag below the secondary bag with the secondary bag’s
clamp wide open, gravity will ensure that the secondary (higher) bag will infuse and
the primary bag will stop infusing.
7. When verifying the IV medication flow rate, what is the advantage of counting
for a full minute versus half or 15 seconds?
The rate may speed up or slow down over the course of the minute. Counting for
a full minute ensures an accurate count.
IV.J.3.a
UNIT IV
Section J.3
IV Push Medication
Critical Elements for Injectable IV Push Medications
administration
2. Selects the prescribed medication using the Medication
Administration Record (MAR)
3. Records the correct calculation of the prescribed dose on the
Simulation Laboratory Form before administering the medication.
a.
Patient name
b.
Date of birth
c.
7. Administers the prescribed medication to the designated patient.
8. When IV medication is to be administered by push:
a.Records the volume of medication and time to be administered on
the Simulation Laboratory Recording Form before administering the
medication
b.Assesses the insertion site for dislocation, infiltration or other
complications immediately before administering the medication by
using one of the following methods:
1)
Feeling around the skin for changes in temperature
2)
c.
Injects the medication at the designated rate
d.
OR
1)
Aspirates for blood return unless contraindicated
IV.J.3.b
2)Flushes with the prescribed solution prior to
medication administration
3)Flushes with designated solution after
9. Records medication administered on medication
10.Maintains asepsis
11.Completes all the Critical Elements in 15 minutes
Administer the medication complying with established guidelines for medication
administration, utilizing the six rights of medication administration, and maintaining
asepsis. Prepare the medication, administer it to the patient, and record the
medication you administer on the MAR.
The station will be set up with all the supplies you will need. For the purpose of
the CPNE Simulation Laboratory, IVP medications will be administered through a
needleless intermittent venous access device anchored to a model of an arm. You will
not be responsible for assessment of vital signs or patient response to the medication.
1. Complies with established guidelines related to
Contaminated needles and other contaminated sharps shall not be bent,
recapped, or removed. Place used syringes and needles, scalpel blades or
other sharps in designated puncture-resistant sharps containers.
If a designated puncture-resistant sharps container is not readily available,
recapping of the needle may be performed using the one-handed scoop method.
The syringe and needle are to be disposed of in a designated puncture resistant
sharps container as soon as feasibly possible.
Select the assigned medication from a group of medications on the table at the
station using the MAR. The medications at the station will be in liquid form in
labeled multi-dose vials. A list of the medications that might be assigned at the
station is provided below.
Medications to be administered at the
Injectable IV Push station may include the following:
IV Push
Lasix
Reglan
Benadryl
Bumex
Zofran
Synthroid
Dexamethasone
Toradol
IV Push Medication
IV.J.3.c
Read the MAR completely before you start to prepare your medications.
Dates Administered
Digoxin 0.25 mg IV push
Administer over 2 minutes.
Time
}
6/13
1400
Flush intermittent venous
access device with 1 ml normal
saline before and after bolus
medication
(give 1400 dose)
Signature Record
Signature
Initials
CHF
Patient Name: ______________________________
Diagnosis: ____________________________
643210
12 - 15 - 36
Date of Birth: _______________________________
No Known Allergies
Allergies: ___________________________________
IV.J.3.d
3. Record the correct calculation of the prescribed dose on the Simulation
Laboratory Recording Form before administering the medication.
Calculate and draw up in a syringe the correct dose of the medication. You
will be provided with a Simulation Laboratory Recording Form to calculate
and record the correct dose. After you complete the calculation, take the time
to check your computation carefully to be sure you have not made an error.
You may use a calculator for all calculations during the CPNE.
(CPNE)
Name: _ __________________________________________________________
Station C: Injectable Medications: IV Push
IVP Medication
__________ ml
__________ minutes
IV Push Medication
IV.J.3.e
The medication vials will have vial adapters attached. These adapters can be
accessed using needless syringes. Remove any air inadvertently drawn into the
syringe in order to draw up an accurate dose of the assigned medication
Draw up the designated medication in a syringe and measure the dosage with
100% accuracy. Once you have measured the correct dosage of the medication,
you will be expected to hand the syringe to the CE, so that the CE can verify that
you have the correct dosage of the medication.
a.
Patient name
b.
Date of birth
b.
record number. Be very deliberate in this action because the CE may not be able
to observe you visually scanning the ID band.
Once you have prepared the medication listed on the MAR, administer the
prepared medication to the designated patient.
The syringe will access the venous device without the use of a needle. A new
syringe is required each time you enter the venous access device. Alcohol wipes
will be available for your use.
Be mindful to protecting the end of the Luer-Lock syringe after you draw up the
flush solution and the IV push medication. The syringes have either a plastic or
paper cover and these covers may be used to maintain asepsis.
a.Records the volume of medication and time to be administered
on the Simulation Laboratory Recording Form before administering
the medication.
IV.J.3.f
b.Assesses insertion site for dislocation, infiltration, or other
complications immediately before administering medication
1)
Feeling around the skin for changes in temperature
2)
OR
Palpating surrounding tissue for edema.
Write the volume of the medication to be administered and the amount of time
for administration of the IV push medication on the Simulation Laboratory
Recording Form in the space provided prior to administering the medication.
Once you have calculated the volume to be administered, write it in the space
provided. The amount of time over which you will be expected to administer the
IVP medication will be written on the MAR.
Assess the IV insertion site for dislocation, infiltration, or other complications
immediately before administering the medication. If the site is free of redness,
edema, and pain, you may gently flush the IVAD following aspiration for blood
return. If it flushes without resistance, it is all right to use the site. In the nursing
Simulation Laboratory, you will perform all the Critical Elements even though
you would not actually see these signs or symptoms of redness, edema, and
pain.
c.
Inject the medication at the designated rate. The CE will evaluate the rate
of injection at each of the quarter marks during the injection. Deliver the
appropriate amount of medication over each quarter interval. To determine the
amount of fluid to inject in a quarter, first determine the amount of medication
to be injected and divide that number by four. Pushing the entire amount to be
delivered in the quarter during the first few seconds of that interval and then
waiting for the next interval may place the patient in Physical Jeopardy and
would not be acceptable during the CPNE. Gradually and continuously deliver
the amount of medication so that the correct dose is administered in the correct
time interval.
It is important to notify the CE when you are about to begin injecting the
medication. Place your watch where both you and the CE will have a
comfortable view of it. When you are ready to administer the medication,
using your watch state, “I will begin the injection when the second hand gets
to the ____.” When the injection is completed state “stop.”
Identifying medication injection rate: An Example
You are to administer Digoxin 0.25 mg IVP (0.125 mg/ml). The volume equals 2
ml. Administer over 2 minutes. Divide the total volume by 4. This gives you the
maximum amount to push per quarter: 2 ml = 0.5 ml.
4
IV Push Medication
IV.J.3.g
Next, divide the total minutes in seconds by 4. This gives you the time interval
for each quarter:
120 seconds = 30 seconds
4
This means that you would push no more than 0.5 ml every 30 seconds.
The CE will check your rate at the quarter mark, halfway, and three-quarters
mark. If you exceed the ordered rate at the halfway mark or if you complete the
medication administration sooner than ordered, it is a failure. If this occurs in
Simulation Laboratory 1, you would be allowed to complete the station for the
purpose of practice, then repeat the lab station during Simulation Laboratory 2.
It would not be considered a failure if you administer the medication more
slowly than ordered.
d.
1)
Aspirate for blood return unless contraindicated
2)Flushes with designated solution and volume prior
to medication administration
3)Flushes with designated solution and volume after
Prior to initiating the first flush you are to aspirate for blood return. Even though
you will not see a blood return during the Simulation Laboratory, it is essential
that the CE observe you performing this Critical Element.
Flush the IVAD prior to and immediately following administering the IV push
medication. The designated flush solution you will use is normal saline. It will
be available at the station table as an IV solution bag hanging on an IV pole.
Withdraw the flush solution from the IV bag which has a one way valve inserted
into the opening of the bag. This means you cannot push solution back into the
IV bag once the flush solution is drawn off.
The designated solution and amount of flush will be written on the MAR.
Prepare two syringes of ordered flush, one to be used prior to administering
the medication and the other to be used after the medication is administered.
Show the CE your syringes prior to flushing the IVAD. Use gentle pressure
when flushing the intravenous catheter. Do not attempt to instill the designated
solution if you feel resistance. Do not flush before and after the medication
administration using the same syringe of flush solution. It is not acceptable to
administer more than the designated volume of flush solution.
9. Records the medication administered on the patient’s medication record
Place your initials on the MAR in the box corresponding to the time the
medication was administered and place your signature in the space provided at
the bottom of the MAR.
IV.J.3.h
10.Maintain asepsis
Standard Precautions are to be maintained. For injectable IV medications, be
aware which parts of the syringe must remain sterile e.g., inside barrel and the
plunger. For IV medications, it is necessary to cleanse the port with alcohol
before inserting the IV access pin. Gloves are worn during IV push medication
administration and administration of the flushes to protect the hands from
possible exposure to blood.
Critical Thinking/ Application to Practice
1.
Toradol 30 mg IVP
Available: 30 mg/ml
Inject slowly over 1 minute
How many mls would you give over the first quarter of the designated
time frame to deliver the IV push medication?
2.The access to the flush solution is a one-way back-check valve.
What would you do if you drew up more than the designated volume
of flush solution?
Station C: Injectable Medications: IV Push
1. Administer Toradol 30 mg IVP, Available = 30 mg/ml
1 ml inject over 1 min. Using your watch to push one quarter of the dose over the
designated time, you would push 0.25 ml over 15 secs.
2. The access to the flush solution is a one-way back-check valve. What would
you do if you drew up more than the designated volume of flush solution?
Discard the excess flush solution in the trash receptacle at this station. It is not
acceptable to administer more than the designated volume of flush solution.
IV.J.4.a
UNIT IV
Section J.4
Injectable Medication:
Intramuscular or Subcutaneous
Critical Elements for Injectable Medications:
Intramuscular or Subcutaneous
1. Complies with established guidelines related to medication administration
2.Selects the prescribed medication using the Medication Administration
Record (MAR)
3.Records the correct calculation of the prescribed dose on the Simulation
Laboratory Recording Form before administering the medication
5.Identifies the patient immediately before administering the medication by
verifying two of the following pieces of patient information:
a.
Patient name
b.
Date of birth
c.
6. Uses the correct needles size for injections
9.Records medication administered on medication administration record
(MAR)
11. Completes all the Critical Elements in 15 minutes
At the Injectable IM/subQ Medication Station, you will be mixing two medications for
administration by subcutaneous or intramuscular injection.
The station will be set up with all the supplies you will need. For the purpose of the CPNE
Simulation Laboratory, IM or SubQ medications will be administered to a model of a
torso with a buttocks. You will not be responsible for assessment of vital signs or patient
response to the medication.
IV.J.4.b
1. Complies with established guidelines related to
For successful completion of this Simulation Laboratory Station administer the
medication complying with established guidelines for medication administration,
utilizing the five-rights of medication administration, and maintaining asepsis.
Prepare the medication, administer it to the patient, and record the medication
you administered on the MAR.
Currently, the American Diabetic Association is recommending that health care
providers not aspirate when administering an insulin injection. Based on this
recommendation, it is not a point of failure if you do not aspirate when
administering insulin in the Simulation Laboratory or during a PCS.
An example of established guidelines for injectable IM subQ medications
includes aspirating for a blood return prior to injecting an intramuscular
medication. If this step were omitted, the station would be considered failed.
Be prepared to mix long acting and short acting insulin at this station. For the
simulation, the regular insulin will be clear and NPH insulin will be cloudy.
Therefore, roll the NPH insulin vial before you draw up the prescribed dose of
NPH insulin.
Check the accuracy of the dosages you have drawn up in the syringe before
giving it to the CE for evaluation.
Based on a random assignment, you could administer either a subQ or an
IM injection. Consider the medications to be mixed in the same syringe to
be compatible.
Select the assigned medication from a group of medications on the table at the
station using the MAR. The medications at the station will be in a liquid form in
labeled multidose vials. A list of the medications that might be assigned at the
station is provided below.
Medications to be administered at the Injectable Medication
station may include the following:
subQ
Regular Insulin
NPH Insulin
Humalog (lispro)
IM
Compazine
Toradol
Benadryl
Nubain
Injectable Medication: Intramuscular or Subcutaneous
IV.J.4.c
Dates Administered
Humulin R (regular) Insulin
12 units subQ
Humulin N (NH) 30 units subQ
Time
}
6/13
1800
Give 1800 dose
Signature Record
Signature
Initials
Left hip replacement
Patient Name: ______________________________
Diagnosis: ____________________________
5/05/45
643210
Date of Birth: _______________________________
No Known Allergies
Allergies: ___________________________________
IV.J.4.d
3. Records the correct calculation of the prescribed dose on the
Simulation Laboratory Recording Form before administering
the medication.
Calculate the correct dose in a syringe for each medication to successfully
measure the prescribed dosage. The Simulation Laboratory Recording Form
will be provided for you to do your calculations. A sample of the Simulation
Laboratory Recording Form is provided below. After you complete the
calculation, take the time to check your computation carefully to be sure
you have not made an error. You may use a calculator for all calculations
during the CPNE.
(CPNE)
Name: _ __________________________________________________________
Station D: Injectable Medications
IM/Sub-Q Medication
Drug
Volume of Dose
Identify first
medication and dose
Identify second
medication and dose
Correct total dose
IV.J.4.e
Draw up the designated medications in a syringe and measure the dosage with
100% accuracy. You will be assigned to mix two compatible medications at this
station. Remember to check the syringe for air; remove any air prior to handing
the syringe to the CE for evaluation.
Once you have measured the correct dosage of the first medication, hand the
syringe to the CE prior to drawing up the second medication so that the CE
can verify that you have the correct dosage of the first medication. If the first
medication dosage was incorrect, the station would be considered failed at that
time. You will be directed to complete the station for practice during Simulation
Laboratory 1.
a.
Patient name
b.
Date of birth
c.
record number. Be very deliberate in this action because the CE may not be able
to observe you visually scanning the ID band.
6. Uses correct needle size for Injections
You will be assigned to give either a subcutaneous or intramuscular injection.
Know the various needle gauges and lengths and choose accordingly in order to
administer the medication as prescribed. Packaging of supplies varies from site
to site, therefore it would not be advisable to rely on the color of the package to
identify the correct needle size and syringe.
You may be administering insulin. Insulin syringes are calibrated in units/ml.
The standard insulin syringe is calibrated in increments of 100 units/ml.
7. Uses prescribed route and/or site for administering medications
Once you have prepared the medication listed on the MAR, administer the
medication to the designated patient using the prescribed route and site.
Inject the IM or subQ medication into the appropriate site on the mannequin.
IV.J.4.f
The IM/subQ injection model is anatomically correct and simulates the buttocks
of a small adult. The bony landmarks can be palpated on the model. Choose the
site you think is most appropriate for the injection.
Intramuscular injections may be given in ventrogluteal, vastus lateralis, and
dorsogluteal sites. The ventrogluteal site is the preferred site for injections as
this site is located away from large blood vessels, nerves and bone. The Z-Track
method prevents “tracking” and is used for administering medications that are
especially irritating to subcutaneous and nerve tissue.
9.Records the medication administered on the patient’s
medication record.
Place your initials on the MAR in the box corresponding to the time the
medication was administered and place your signature in the space provided at
the bottom of the MAR.
10.Maintain asepsis
Standard Precautions are to be maintained. For injectable IM/subQ medications,
be aware which parts of the syringe are sterile e.g., needle, inside barrel and
the plunger. Before inserting the sterile needle into the vial for the IM/subQ
injection it is necessary to cleanse the rubber stopper with alcohol. Gloves are
worn during the IM/subQ injection to protect the hands from possible exposure
to blood.
Prepare, administer, and record the medication administered in 15 minutes.
1.
The following medication order is written on your MAR.
Robaxin 0.3 gram IM
Available 100 mg/ml
How many ml of Robaxin would you administer to the patient?
2.List the acceptable subcutaneous and intramuscular sites for
3.When drawing up NPH and regular insulin in the same syringe,
which of the insulins would you draw up first?
Why?
4.Why should you roll the vial of NPH insulin before drawing it up?
5.List 3 strategies you could use to minimize the entry of air into the
syringe while drawing up IM or subQ medication.
IV.J.4.g
Station D: Injection Medication Station
1. The following medication order is written on your Medication
Administration Record:
Robaxin 0.3 Gm/IM.
Available: 100 mgs/ml.
How many mls. Of Robaxin would you administer?
1000 mgs = 1 gm
0.3 Gm = 300 mgs
Divide 300 by 100 = 3 mls
If your answers are wrong review the formulas. Did
you insert the right numbers in the correct place
in the formula? Continue reviewing your calculations until you are consistently getting the correct
answers.
2. List the acceptable subcutaneous and intramuscular sites for medication
administration.
Subcutaneous injections are usually administered in the anterior aspect of the
upper arms, thighs and abdomen. Intramuscular sites include deltoid, dorsal and
ventrogluteal, vastus lateralis and rectus femoris. Refer to a nursing fundamentals
or skills textbook for more detailed information.
3. When drawing up NPH and Regular insulin in the same syringe, which of the
insulins would you draw up first?
Regular.
Why?
You do not want to contaminate the shorter acting Regular insulin with the longer
lasting NPH insulin.
4. Why should you roll the NPH insulin before drawing it up?
Rolling the vial of NPH insulin ensures that the suspension particles are evenly
mixed. This will ensure that each dosage is uniform
5. List three strategies you can use to minimize the entry of air into the syringe
while drawing up an IM or subQ medication.
Invert the vial, keep the needle below the fluid level, withdraw the fluid slowly and
tighten the needle on the syringe.
IV.J.4.h
App.1
Appendix Listing
A. CPNE Definitions
B. Regional Performance Assessment Centers (RPACs)
C. Academic Honesty
D. CPNE Student Orientation
E. Universal Time chart (24 hour clock)
F. Simulation Lab Orientation Guide
G. Simulation Laboratory Report
H. Blank Student PCS Response Form
I.
Study Plan Time Analysis
J. Self-Assessment
K. Patient Care Situation (PCS) Scoring Tool
L. Excelsior College Statement on Precautions for Infection Control
M. Reasonable Accommodations
N. Approved and Unacceptable Abbreviations
O. Additional Practice Care Plans
P. State Board Information
App.A.1
Appendix
A
CPNE DEFINITIONS
Areas of Care
They are clusters of nursing activities that incorporate similar principles or
competencies. The content tested during the CPNE is listed within Areas of Care.
Areas of Care are categorized as Overriding, Required, and Selected. Critical elements
contained within the Areas of Care are detailed in Unit IV of this study guide.
Assigned Areas of Care
They include two required Areas of Care, three to four selected Areas of Care based
on the patient’s condition, and all overriding Areas of Care for the examination.
Clinical Decision Making
A problem-solving process by which choices are made in nursing practice. This
process involves the identification of patient problems, selection of a course of action
or nursing intervention, and evaluation of a patient’s progress in response to the
patient’s situation based on theories, scientific principles, established protocols, and
pertinent references.
Students demonstrate Clinical Decision Making in the CPNE during all phases of the
nursing process as it is defined in the study guide. The Clinical Examiner observes your
Clinical Decision Making throughout your implementation of the Critical Elements.
When you make a deliberate decision to modify or omit a Critical Element, verbalize
the reason for the modification or omission prior to implementing that modification
or omission.
Critical Elements
Are single, discrete, observable behaviors that you must perform to met the
standard of acceptability for the Areas of Care being tested. Because the designated
competencies are set at the minimum level acceptable for beginning nursing practice,
all Critical Elements are to be performed as specified. You will find that some Critical
Elements need to be completed within a specific timeframe or in a specific order.
Established Guidelines
The standards of nursing practice that guide nursing actions. These standards are
found in nursing text books and references, accepted by the nursing community
based on nursing and scientific knowledge that lead to the best possible patient
outcomes. An example of an Established Guideline is: rotating a vial of NPH insulin
prior to withdrawing for injection.
App.A.2
Evaluation Phase
The period of time in the PCS you will record the findings of the implementation
process that has been ongoing since the beginning of the PCS. During this phase
document the assessment findings and patient’s response to interventions, write
any necessary revisions in the nursing care plan, and evaluate the effectiveness
of that plan.
For Information Only
This is noted on the PCS response form to give the student more information about
the patient, but does not require a nursing intervention by the student.
Implementation Phase
The period of time in the PCS when you will be administering nursing care to an
assigned patient.
Infusion Control Device (ICD)
A mechanical device that regulates the administration of fluid. Commonly referred
to as IV pump or feeding pump.
Jeopardy
Emotional: Any action or inaction on the part of the student that threatens the
emotional well-being of the patient or significant others.
Physical: Any action or inaction on the part of the student that threatens the
patient’s physical well-being.
Noxious Stimuli
Irritating physical sensations that are applied to a patient who is nonresponsive to
verbal stimuli during a neurological assessment to ascertain the patient’s sensory
motor response. Such stimuli may or may not be painful but should not be harmful to
the patient.
Nursing Care Plan
A written communication tool for patient care, found in the Student PCS Response
Form, which the student develops. See the Critical Elements for Planning and
Evaluation Phase.
Nursing Diagnosis Statement: includes a: (1) nursing diagnostic label of an actual
problem, (2) the contributing/etiological factor(s), and (3) signs and symptoms.
Actual Diagnosis: An actual nursing diagnosis describes a clinical judgment
that the nurse has validated because of the presence of major or minor defining
characteristics, or signs and symptoms.
Appendix A
CPNE Definitions
App.A.3
Defining Characteristics: For actual nursing diagnoses, defining characteristics
are a single sign or symptom or a cluster of signs and symptoms that validate the
existence of the problem.
Risk Diagnosis: A risk nursing diagnosis describes a clinical judgment that an
individual/group is more vulnerable to develop the problem than others in the same
or similar situation. A risk diagnosis consists of two parts; the diagnostic label and
risk factors present (etiology).
Nursing Diagnostic Labels: A list of specific NANDA approved labels describing
health/illness states (problems) used in writing the nursing diagnosis.
Etiological Factors: Identifies the contributing or related factors that confirm the
selection of the diagnostic label. These factors may be pathophysiologic, treatmentrelated, situational, or maturational factors that can cause or influence the health
status or contribute to the development of a problem.
Signs and Symptoms: Pathophysiological and/or treatment-related factors that can
cause or influence health status or contribute to the development of a problem.
Expected Outcome: A statement of anticipated change in or maintenance of the
patient’s health status related directly to the nursing diagnosis and to nursing interventions. The characteristics of an expected outcome are that it is measurable,
realistic, and specific in content. An expected outcome answers the question “what
is the patient expected to achieve as a result of nursing interventions?”
Nursing Intervention: An activity (action) performed by a nurse to assist patients
toward attainment of the expected outcomes. Nursing interventions need to be
consistent with standards of safe nursing practice and the medical regimen.
Nursing Process
A problem-solving process that is cyclical in nature and consists of five components:
Assessment: the process of gathering and synthesizing data about the patient’s
health status.
Analysis: the identification of the nursing diagnosis (patient problem) and the
determination of the expected outcomes (goals of patient care).
Planning: the formulation of objectives and specific activities to achieve the
expected outcomes.
Implementation (Intervention): the carrying out of the nursing plan designed
to move the patient toward the expected outcomes (i.e., if I do this, then the patient
will achieve or be moved toward the expected outcome).
Evaluation: the appraisal of the patient’s progress toward the expected outcomes.
Note: In the CPNE these five components are collapsed into three phases for each PCS:
Planning, Implementation, and Evaluation.
App.A.4
Nursing Theory Examinations
Refers to the content of the nursing curriculum that is measured by computer testing
rather than performance testing.
Are ever-present areas of concern inherent in nursing practice and hence tested
throughout the CPNE. These are Asepsis, Caring, Emotional Jeopardy, Mobility, and
Physical Jeopardy. The overriding Areas of Care are “always in effect,” which means
every action that you take during the CPNE will be evaluated using the Critical
Elements within the overriding Areas of Care.
Patient Care Situation (PCS)
2-½ hour period of time during which you provide care (through the assigned Areas
of Care) to one patient under the direct observation of a Clinical Examiner (CE). Each
PCS requires the application of all components of the nursing process.
Patient Care Situation Recording Form and Narrative Note
A portion of the Student PCS Response Form that the student uses during the PCS to
document nursing care administered; it is equivalent to nurse’s notes or progress
notes typically used in charting nursing care.
PCS Assignment Kardex
A portion of the Student PCS Response Form where the CE writes pertinent data about
the patient and assigned Areas of Care you are to perform during the PCS.
Planning Phase
The period of time in the PCS when the student analyzes the patient’s data and
writes the Nursing Care Plan prior to initiating nursing care. During this phase of the
CPNE, you will write the nursing diagnostic labels, expected outcomes, and nursing
interventions on the NCP.
Regional Performance Assessment Center (RPAC)
A testing center which administers the Excelsior College Nursing Performance
Examinations. The Center provides access to the comprehensive nursing performance
examinations for Excelsior College nursing students as well as by students in other
nursing programs that have contracts with the college. All RPACs, with the exception
of the Southern Performance Assessment Center, are sponsored by Excelsior College.
Appendix A
CPNE Definitions
App.A.5
Specific aspects of nursing care that all students must perform successfully during
the PCS. Every PCS will include the two Required Areas of Care: Vital Signs and Fluid
Management.
Selected Areas of Care
Specific aspects of nursing care that, in addition to the Required Areas of Care, are
assigned by your CE based on the patient’s needs. Therefore, Selected Areas of Care
may vary from one PCS to another based on the needs of the patient. The Selected
Area of Care “Medications” must be successfully completed at least once during the
CPNE.
Significant Other
A person whom the patient perceives or identifies as supportive and essential. This
may be a parent, child, spouse, relative, or friend.
Simulation Laboratory
The portion of the examination that takes place in a skills laboratory setting where
you demonstrate Critical Elements on mannequins. Skills tested include administering
medications by injection, administering IV medication by push, administering IV
medication by minibag (IVMB), and packing a wound with a wet to moist sterile
dressing.
Simulation Laboratory Report
A scoring tool which the Clinical Examiner uses to score your performance during the
Simulation Laboratory component of the CPNE.
Student PCS Response Form
The official documentation form for the CPNE. The CE gives the PCS Response Form
to you at the beginning of each PCS. The form contains your patient assignment as
well as areas for you to document your findings during the PCS.
When Designated
A term to identify information provided by the Clinical Examiner on the PCS
Assignment Kardex which is needed in order to complete the PCS assignment.
Critical Elements that are “designated” are to be performed i.e., oxygen saturation,
application of heat/cold etc.
App.A.6
App.B.1
Appendix
B
Regional Performance Assessment Centers
Georgia
Southern Performance Assessment Center (SPAC)
3032 Briarcliff Road NE
Atlanta, Georgia 30309-2655
404-325-5536 x101
[email protected]
New York
Northern Performance Assessment Center (NPAC)
Excelsior College
7 Columbia Circle
Albany, New York 12203-5159
888-647-2388 (at the automated greeting, press 1-3-1-2)
[email protected]
Wisconsin, Ohio, and Texas
Mid-Western Performance Assessment Center (MPAC)
6117 Monona Drive, Suite 4
Madison, Wisconsin 53716
800-439-6572
[email protected]
App.B.2
Regional Performance Assessment Centers
NPAC
Albany, NY:
Albany Medical Center,
St. Peter’s Hospital
Schenectady, NY:
St. Clare’s Hospital
Ellis Hospital
Syracuse, NY:
St. Joseph’s Hospital and
Health Center
SUNY Health Science Center–
University Hospital
Crouse Hospital
MPAC
SPAC
Madison, WI:
Meriter Hospital,
St. Mary’s Hospital and Medical Center
Atlanta, GA:
Grady Memorial Medical Center,
Gwinnett Regional Medical Center,
Southern Regional Medical Center
Racine, WI:
All Saints Medical Center
Mansfield, OH:
Med Central Health Systems
Utica, NY:
Faxton/St. Luke’s Health Care
Savannah, GA:
Memorial Health
Plano, TX:
Medical Center of Plano
Amarillo, TX:
Northwest TX Healthcare Systems
App.C.1
Appendix
C
Academic Honesty
Academic Honesty (Policy # 116102)
Statement of Policy
Honesty is the cornerstone of the academic integrity of Excelsior College.
Consequently, any form of academic dishonesty is considered to be a serious violation of the ethics that form the foundation of all Excelsior College academic programs.
Academic dishonesty includes: altering or misusing documents; impersonating, misrepresenting or knowingly providing false information as to one’s identity; providing
false information regarding completion of course assignments, professional history, or
accomplishments; cheating on examinations; plagiarism; attempting to gain advance
information on examination questions from any source, or collaborating with others
for that purpose; and sharing information about examination questions or content
via electronic discussion groups or in any other way by a student who has taken an
examination. Students are accountable for dishonest acts committed prior to and
during enrollment with the college, as well as after separation from the college
through withdrawal or graduation. The term “students” includes test takers, prospective students and enrolled students, and Excelsior College graduates. Students who
engage in acts of academic dishonesty related to Excelsior College may be denied
admission or continued enrollment in Excelsior College and/or further access to
Excelsior College examinations for courses.
You are responsible for protecting the integrity of your responses when you are
taking an examination. Any form of academic dishonesty will be considered a
serious violation of our academic policies.
Procedures
Staff who suspect a breach in academic honesty will immediately contact the
appropriate dean who will communicate with the student until the situation is
resolved. The Dean presents the student’s case to The Academic Affairs Council.
AAC determines the action to be taken.
Specific to cases where apparently false documentation is submitted, an investigation
is conducted. In the cases where it is confirmed by the Records Office that a fraudulent document such as a transcripts, diploma, certification, etc., has been submitted,
the student will be notified in writing by the Director of Records of the violation and
the action that the College will take.
When there is evidence of academic dishonesty, the student will be notified in writing
of the nature of the violation and the action that the college will take; all services to
the student may be suspended during this period. The student has 30 days to appeal
App.C.2
in writing, but may not withdraw or graduate from the college or register for any
Excelsior College examinations or courses during those 30 days. For students residing
overseas the period to appeal is 45 days. If the student chooses to appeal, the appeal
will be considered by the Academic Affairs Council and the student will be notified in
writing of the final action.
Excelsior College reserves the right to take any or all of the following actions:
1. Bar a prospective student who is found to have committed an academically
dishonest act from enrolling in the College.
2. Dismiss or suspend from the college, or assign a failing grade to an enrolled
student who has engaged in an academically dishonest act. If a student is
dismissed, the college reserves the right to revoke all credits earned. If the
student has withdrawn or graduated, the credits and/or degree and diploma
may be revoked.
3. Permanently annotate the student’s record to reflect actions taken against
a student who has engaged in academic dishonesty.
4. Notify educational institutions, licensing or certification boards, employers
or others, who have previously received a transcript or similar certification
e.g., Letter of Completion (LOC), Letter of Qualification (LOQ) of any action
taken by the College.
5. Terminate all college services previously available to the student who as been
suspended or dismissed for engaging in an academically dishonest act.
6. Retain all tuition and fees paid by the student prior to suspension or dismissal.
7. Prohibit re-enrollment in Excelsior College except by appeal.
8. Take other action, as appropriate.
A student who has been denied enrollment, exam or course registration, or has been
dismissed because of a violation of the Academic Honesty Policy may petition for
reconsideration no sooner than two years from the date of the decision. The petition
must be in writing and must present a rationale for reconsideration, and shall be
addressed to the Vice President for Academic Affairs and Provost at Excelsior College,
7 Columbia Circle, Albany, NY 12203. The Academic Affairs council will review the
petition and supporting documents within 30 days of its receipt, and notify the student
in writing of the decision.
If an appeal is granted, the student will be admitted to Excelsior College under the
degree requirements in effect at the time of readmission.
Degrees previously revoked will not be reinstated.
App.D.1
Appendix
D
CPNE Student Orientation 2007
I.Welcome
II.Photograph Identification, Forms, and Declaration
III.Role of Clinical Associate
IV.Role of Student
V.Role of Clinical Examiner
VI.Suggestions and Reminders
VII.Orientation to the Hospital
VIII.Determination of the Rotation
App.D.2
Clinical Performance in Nursing Examination (CPNE)
Student Orientation
I.Welcome
A.Welcome to the Clinical Performance in Nursing Examination. I will be
reading this orientation to you since we want to be sure that all students
taking the CPNE receive the same information. Please hold your questions
until the end since many of them may be answered as we go through this
orientation. Write down any questions that you have and I will answer
them at the end. If you wish, you may follow along using the copy of the
Student Orientation on the table in front of you. Please do not write on
this copy.
B.My name is _______________________________ and I am your Clinical
Associate for the weekend. I would like to ask each of you to introduce
yourself to me and each other. (Encourage names only, to limit time spent
during orientation.)
C.Your name tag is your identification for the weekend. Please put it on.
D.Please write down where you will be staying and your phone number
for the weekend on the sign-in sheet in your packet; this will allow me
to contact you, if needed.
E.I can be reached at the hospital (give telephone number and/or beeper
number). If you have any questions/concerns, or are unable to meet me at
the designated time, please call.
F.Please note that the *14th edition of the CPNE study guide is in effect.
You are responsible for implementing nursing care according to the
2007 edition.
*(Hold up copy)
II. Photograph Identification, Forms, And Declaration
A.Please take out your photo ID that you were asked to bring. I am now going
to verify your identification with the photo attached to your application.
B.If you have any conditions that might influence your ability to provide
patient care, please tell me today after this orientation, in private.
C.Is there anyone who is currently employed at this hospital? (If so, we will
arrange the rotation pattern so you will not be assigned to floors you have
worked on in the last two months.)
Appendix D
CPNE Student Orientation
App.D.3
D.Please take out the Simulation Laboratory Report (SLAR) and in ink fill
in your name and (social security number). Enclosed in the SLAR are
recording forms. Please fill in your name and (social security number) on
these forms and put them back in the SLAR. These forms are used at the
medication stations during the Simulation Laboratory.
E.Next, please take out the form entitled “Official Student Examination Record
(OSER).” In ink, fill in the information at the top and circle the degree
program in which you are currently enrolled. (Hold up example.) This record
becomes part of your permanent file. Please complete this section and hand
it in to me.
F.Please look at the names of the Examiners listed on the board. In order to
achieve as neutral a situation as possible, we recommend that someone
who is not an acquaintance of yours examine you. If any of the Examiners
are familiar to you, please identify the team that the Examiner is on, and I
will assign you to the other team. (Allow time for students to respond.)
III.Role of Clinical Associate
A.I am a representative of Excelsior College School of Nursing, and I must be
sure that the examination is administered according to the guidelines.
B.I will be making rounds during the examination to monitor your progress
as well as the progress of the exam. Examiners will consult with me either
during my rounds, or by phone, when they have questions about your PCS.
C.You may ask me questions or request to speak with me at any time
throughout the weekend. However, you need to understand that my role
is not that of an instructor, but as a facilitator and manager of the CPNE
process.
IV. Role of Student
A.We ask that you not tell Examiners any personal information. In addition,
we ask that you not discuss the examination with your fellow students
because it only increases everyone’s anxiety. Please focus on your own
performance.
B.As a student during the CPNE, you will have access to patient information.
All patient information is to be kept confidential.
C.You are referred to as a “student” and the Examiner as an “instructor”
during this examination. If a patient asks, you may say, “I’m being
evaluated as part of my nursing program.”
D.As an Excelsior College nursing student, you are not to be in any patient
care areas without the direct supervision of a Clinical Examiner.
App.D.4
E.When documenting on the MAR, follow your signature with the
abbreviation for Excelsior College student nurse. This is initialed ECSN (refer
to the initials that you have written on the blackboard).
F.You will be evaluated as a first day new graduate on the unit. We
encourage you to be an advocate for yourself by being assertive. Ask
questions and use the resources available on the unit to assist you in being
successful during the CPNE.
G.You are expected to present yourself in a professional and academically
honest manner throughout the CPNE. You are not allowed to chew gum or
to bring to the nursing unit any electronic equipment, including cell phones,
programmable calculators, PDAs, programmable multifunction watches,
recording/playing devices, or any other electronic device not required for
the CPNE. Please note that any means of sending/receiving messages is
not allowed during the CPNE. Should you choose to bring any electronic
equipment with you, before you leave for your PCS the items will need to
be left behind in the hub room and the Excelsior College faculty cannot be
responsible for their security.
H.After completing the CPNE, if for any reason you become ill with a potentially communicable illness, please report this to the College. Then, if any
follow up is needed, the College will be able to discuss this with you.
V.
Role of Examiner
A.The Examiner’s responsibilities are to:
objectively evaluate your performance,
and
protect the patient from physical and emotional jeopardy.
The Examiners will observe all aspects of your nursing care and be with
you at all times throughout each PCS. The Examiners will give you every
opportunity to recognize and correct any errors as long as a critical element
has not been omitted or performed incorrectly, for example, if you are
applying a sterile dressing and you recognize that you have contaminated
your sterile gloves, you may discard the contaminated gloves and put on
a new pair.
B.If you ask an Examiner a question that requires teaching as part of the
answer, they may say, “I’m sorry I can’t answer that question because it is
of a teaching nature.” However, we encourage you to ask the question if
you are unsure since the Examiner may be able to answer or refer you to
someone or something that might answer your question.
Appendix D
App.D.5
VI. Suggestions and Reminders
A.In addition to Carpenito-Moyet’s or Mosby’s Guide to Nursing Diagnosis
Handbook and your drug reference handbook, you may also use written
and human resources that are available on the units. Some examples are:
procedure manuals, flow sheets, patients’ charts, and the primary nurse.
However, texts, electronic equipment, your notes, any note cards, study
guides, definitions of areas of care, critical elements listed in any form
cannot be taken to the nursing unit and cannot be used at any time
after the PCS has begun. To do so violates professional behavior and the
Excelsior College Academic Honesty Policy. Once the examination begins
on Day 2 you may write critical elements or other memory cues in your
Student Response Form to assist you during the PCS.
B.When you hand in your Nursing Care Plan at the end of the Planning Phase,
the Examiner will determine if the critical elements for Planning were met.
If so, the plan is accepted. After your care plan has been accepted at the
end of the Planning Phase, the Implementation Phase begins.
C.During the Implementation Phase you are to implement the four nursing
interventions you have identified in planning as appropriate to move
the patient toward the expected outcomes. In addition, if you incorrectly
perform or omit any of the critical elements in an assigned area of care,
at that point, the PCS will be considered a failure.
D.You all have seen a copy of the Student PCS Response Form in your Study
Guide. As you complete your assessments and critical elements, you may
use the narrative notes to document your findings. You may complete
this form in pencil. On the Student PCS Response Form, if you do not
have enough space for your notes under a specific area of care, draw
a line through the next heading and continue your note. You are only
required to document on those areas of care that you are assigned. All
recording information will be evaluated using this form with the exception
of medications which are recorded, in ink, on the hospital Medication
Administration Record (MAR). Are there any questions regarding how to
use this form for documentation during the PCS?
E.Changes to the nursing care plan during the Implementation Phase may be
made at any time. These changes must be shown to the CE at the time the
change is made. You will be expected to perform any changes you have
made to the nursing interventions you have written.
F.During the Evaluation Phase, you must continue to develop the nursing
care plan for the patient problem you identify as a priority. Evaluative
statements are required for the rationale for choosing the priority diagnosis
and the patient’s progress toward the expected outcome. The effectiveness
of nursing interventions segment requires you to describe the patient’s
response after you have implemented the intervention. Once you submit
App.D.6
your PCS Response Form to the Examiner, the PCS ends. The Examiner will
then determine if the critical elements for the Evaluation Phase were met
and all requirements for the examination passed.
G.Several procedures are specific for this hospital. I would like to spend the
next few minutes explaining these. (CA to identify specifics of the test site
hospital (e.g., parking.) Please write in those things which you consistently
tell students at this time, (e.g., 24-hour time clock, “military time versus
universal time”, infusion pumps which deliver fluids by infusing volume
over 60 minutes, flow sheets, hospital protocols (e.g., AP for Digoxin, site
used for Heparin administration, Lovenox administration, etc.).
H.There is time for a rest period between each Patient Care Situation (PCS);
this is a time for you to regroup and re-energize by getting something
nutritious to eat, resting your mind and focusing your energy. The cafeteria
is open at _____________ and throughout the day for your use.
I.Additional Reminders
1.Vital Signs — I encourage you to take vital signs twice before you
declare your results to the Examiner. You must inform the Examiner
when these measurements start and stop and how long to count. Let
me demonstrate how to count your vital signs. Looking at the same
watch, you should state, “I am going to start counting at the 12 and
I am going to count for 60 seconds.” I will start the count with one.”
(one being the first palpable or heard pulse, or the first respiration).
You are expected to recognize irregular pulses and irregular respiratory
rates. I recommend that you count the pulse and respirations for one
full minute. (Demonstrate procedure for counting using the student’s or
your own watch).
We suggest, when approaching patients for Vital Signs, that you say,
“I’ll be taking your vital signs twice; this doesn’t mean that there is
something wrong. It is so I can report my most accurate set to my
instructor.”
Electronic equipment is available on the unit for measuring
temperatures, O2 saturation and blood pressures. You may not use the
electronic equipment to measure assigned pulse rates. You must count
the pulse rate with the examiner.
When pain level and/or oxygen saturation is assigned within the area
of care Vital Signs, you must assess and record the level of pain and/
or the oxygen saturation prior to declaring your vital signs.
2.
I Vs — Calculate the IV rate for the primary IV if it is a gravity flow IV and
document it on the bottom of the Care Planning page found in the Student
PCS Response Form during the Planning Phase. For a gravity flow IV, verify
the drops per minute within the first 20-minutes of the Implementation
Appendix D
App.D.7
Phase. If the IV is controlled by an infusion control device, document the
flow rate by writing the setting on the PCS form within the first 20 minutes
of the Implementation phase.
3.Clinical Decision Making — Be sure to verbalize any omission or
alteration of the critical elements. If you do not verbalize why you are
omitting or modifying the critical element, the Examiner has no way of
knowing that you are invoking Clinical Decision Making.
4.
5.Physical Jeopardy — Here, as in all hospitals, the expectation is that we
keep all of our patients safe. Please remember you never step out of reach
of the pediatric patient when the crib rails are down.
6.Pain Assessment — Use a pain scale to aid in the assessment of pain.
For pediatric patients and adults with language or communication
difficulties, the Faces tool may be used. For pediactric patients from 2
months to the age of 3 years, the FLACC tool may be used. The Faces
Ration Scale and the FLACC tool have been included on the Student PCS
Response Form. For adult patients, a scale of 0-10 is used.
sepsis — Remember to wear gloves when coming in contact with any
A
potentially infectious material. Whenever available, it is acceptable to use
an alcohol-based hand rub in lieu of washing with soap and water unless
your hands are visibly dirty.
VII. Orientation to Hospital
A.When you go to the hospital tonight, you will have 30 minutes to complete
your orientation.
1.The Clinical Examiner will orient you to the physical layout of the unit
and if available, to a patient’s bedside unit.
2.At that time, your assignment for the first PCS will also be given to
you. You will be allowed to review the patient record and other patient
related information. You may make notes on your Response Form but
be sure that you do not write down any identifying patient information,
such as the patient’s name, room number and/or social security
number. You will be allowed to take your Student PCS Response Form
home with you tonight to do the Planning Phase of the nursing care
plan. You are not allowed to write any of the critical elements on this
form tonight; only the nursing care plan. Once the PCS begins in the
morning, you may write the critical elements on the Response Form
if that is part of your organization plan. I encourage you to use some
method to organize your patient’s care, and to have something to refer
to during the PCS. This will help to insure that you have performed all
the required critical elements for the PCS.
App.D.8
VIII. Determination of Rotation Pattern
Excelsior College reserves the right to modify the structure and process of the
examination as required by circumstances at the test site. For example, if there were
no appropriate pediatric patients available for your child PCS, a substitution with an
adult patient would occur.
A.Choose a Card
1.Please stand up and each of you select a card at the same time. (The
Clinical Associate holds out the 3×5 assignment cards.)
2.In this way we determine the team, the units, the Examiners, and the
type of patients for the first three (3) PCSs.
B.Complete Rotation Schedule
1.Take out your PCS Rotation Pattern. (Show this form to students.)
2.As I read the team number and letter, please say your name so I can
write it in the appropriate place on the board. You can write in your
own name on your Rotation Pattern. You don’t need to write down the
other students’ rotations.
3.Also write the names of the Examiners from your team on your
Rotation Pattern.
4.Please return the assignment cards to me.
C.Now you should know where your first three Patient Care Situations are
located, and who the Examiners will be. (CA points out which Examiners
they have through the 1st 3 PCSs)
D.I will meet you tomorrow morning at 7:15 in the cafeteria. In the morning,
remember to bring the following materials with you: the Rotation Pattern,
the Student PCS Response Form that you will receive from your first
Examiner later today, pens, pencils and Carpenito-Moyet’s Handbook
of Nursing Diagnosis or Mosby’s Guide to Nursing Diagnosis . You may
choose to bring your drug handbook with you. You may also bring a
nonprogrammable calculator, plus money for a break. The Clinical
Associate, prior to your leaving for the nursing unit for PCS#1 and # 3, will
require you to show them your books and nonprogrammable calculator.
The Clinical Examiner will review these items prior to PCS # 2, 4 or 5.
Please do not bring other electronic devices with you. Please do not bring
valuables with you to the hospital throughout this weekend since we
have no secure place for them and the Excelsior College faculty is not
responsible for their security .
Now, I am going to orient you to the Simulation Laboratory.
(Use Simulation Laboratory Orientation, 2007.)
App.E.1
Appendix
UNIT III
Section
E A
Universal Time Chart
(24-hour Clock)
12:00 Midnight .....................2400
8:00 a.m. . ..............................0800
4:00 p.m. ...............................1600
12:15 a.m. . ..............................0015
9:00 a.m. . ..............................0900
5:00 p.m. ...............................1700
12:30 a.m. . ..............................0030
10:00 a.m. . ..............................1000
6:00 p.m. ...............................1800
12:45 a.m. . ..............................0045
11:00 a.m. . ..............................1100
7:00 p.m. ...............................1900
1:00 a.m. . ..............................0100
12:00 Noon .............................1200
8:00 p.m. ...............................2000
2:00 a.m. . ..............................0200
12:15 p.m. ...............................1215
9:00 p.m. ...............................2100
3:00 a.m. . ..............................0300
12:30 p.m. ...............................1230
10:00 p.m. ...............................2200
4:00 a.m. . ..............................0400
12:45 p.m. ...............................1245
11:00 p.m. ...............................2300
5:00 a.m. . ..............................0500
1:00 p.m. ...............................1300
12:01 a.m. . ..............................0001
6:00 a.m. . ..............................0600
2:00 p.m. ...............................1400
7:00 a.m. . ..............................0700
3:00 p.m. ...............................1500
App.E.2
App.F.1
Appendix
F
Simulation Laboratory Orientation Guide 2007
The first portion of the examination is the Simulation Laboratory. This portion of the
examination is given in a simulated patient care setting. However, you are to perform
as if it were an actual patient situation. You will be evaluated on the same critical
elements used in the hospital setting with the exception that hand washing is not
required during the Simulation Laboratory.
There are four testing stations: A. Wound Management, B. IV Medications, C. IV
Push Medications and D.IM/Sub-Q Injectable Medications. Three of the four stations
require documentation: IV Medication, IM/Sub-Q Injectable Medication and IV Push
Medication. At each of these stations you will be required to document that the
medications were administered by placing your initials in the appropriate box under
today’s date in the 1800 time slot. You will identify the patient by verifying two pieces
of patient information on the identification band. You are not required to identify the
patient at the Wound Management Station.
A card with the critical elements is available at each station during orientation, but
it will be removed prior to the start of the examination. The Simulation Laboratory is
not meant to be a teaching experience. However, I will answer questions about the
testing process and the equipment.
During the 15 minutes of orientation, and throughout the test itself, you are requested
not to talk with each other. However, you can ask me questions if you need
clarification or additional information.
During the Simulation Laboratory, when you have completed each station, the
Examiner will ask, “Have you completed all of the critical elements for this station?”
This is a reminder for you to be sure that you have performed all of the critical
elements for the station.
Wound Management
Station A
• This is the Wound Management Station. You need to gather your supplies and
bring them with you to the patient’s bedside.
•The supplies are:
4"×4" gauze pads, a sterile tray which contains 4"×4" gauze pads, 5"×9"
abdominal pads, the Normal Saline solution, sterile gloves, clean gloves,
and tape. If you are unfamiliar with any of these packages, you may practice
opening them during your personal review time.
App.F.2
•For this lab, the wastebasket is the designated container for disposal
of the dressing.
•This is your patient (point to simulator). This is the dressing you will be
expected to change. The wound requires the application of a moist normal
saline packing layer, followed by the application of a dry sterile dressing with
an abdominal pad cover layer. (lift dressing and show wound)
•You will receive a Sample Treatment Record which will state the type of
dressing and the time the dressing should be changed. You will be responsible
for the 1800 dressing change but you are not expected to document the
dressing change on the treatment record. The treatment record is a sample
and for your information only.
You will have 15 minutes to complete this station.
Intravenous Medications
Station B
•This is the Intravenous Medication Station. The potential medications to be
used are here on the table (point to the medications).
•You will receive a Medication Administration Record (MAR). This form
specifies: (point to each item)
4The IV medication to be given at 1800
4The length of time over which the medication should be administered
and the drop factor of the tubing.
• You will also receive a Student Recording Form.
4 Record the flow rate here (point to the form).
•This is your patient (point to the simulator). Clean gloves are available
to check the IV site.
• The patient’s identification band is located here (show location).
• The station will be set up like this:
4The primary IV bag and the IVMB will be hanging at the same level.
4Lower the primary bag in order to administer the IVMB. Open the
secondary clamp, then use the roller clamp on the primary line to regulate
the flow of the IVMB. (demonstrate)
•The tubing has already been primed. Priming new tubing is not required for
this station. However, during the PCS you will be expected to prime the tubing,
if necessary.
Appendix F
Simulation Laboratory Orientation Guide 2006
App.F.3
•Should you inadvertently get air in the tubing, the back flush method may be
used to clear the secondary line. Lower the secondary bag and tubing below
the primary bag, open the secondary clamp and allow the fluid to expel the air
into the mini bag. (demonstrate)
IV Push Medications
Station C
• This is the IV Push Medication Station.
•The potential medications to be given are here on this table (point to the
medications). These vials have “needleless” adaptors with an airway so you
don’t have to inject air into the vials.
•You will receive a Medication Administration Record (MAR) with the
medication and flush to be administered. You will be giving the 1800 dose.
•You will receive a Student Recording Form. Use it to calculate and record the
volume of medication and the length of time for administration. (point to this)
•This simulator has a “needleless” intermittent venous access device. The
intermittent venous access device is entered without the use of a needle. A
new syringe is needed for each entry.
•Use a 500-ml bag of Normal Saline with a one way adapter to draw up the IV
flushes. This bag of Normal Saline must be accessed with a needleless syringe.
IM/Sub-Q Injectable Medications
Station D
• This is the IM/Sub-Q Injectable Station
•You will receive a Medication Administration Record (MAR) with either two
intramuscular or two subcutaneous medications to be administered in
the same syringe. You will be giving the 1800 dose of the medication.
•You will receive a Student Recording Form. This form provides space to record
each dose: (point to each item)
App.F.4
• At this station you will find:
4Medications
4Syringes and needles
4Simulator (point out landmarks and features on left side of the model.)
You may choose any appropriate site on the model to give the medications.
4ID bracelet
4Sharps container
• Dispose of syringes in the sharps container
• Do not recap used needles
• Record medication given on MAR in the appropriate box
You will have 15 minutes to complete this station
Are there any questions?
You now have 15 minutes to review these stations. You should plan to spend
about 4 minutes at each station. You can ask me questions, but you are not
permitted to talk to each other.
The Simulation Lab will begin at ____________.
App.G.1
Appendix
G
CPNE Simulation Laboratory Report
Clinical Performance in Nursing Examination (CPNE)
I. Student’s Name: _____________________________________________________________
(print)
_____________________________________________________________
(signature)
II.Examiner’s Name:
A. Wound Protection _______________________________________________________
B. Intravenous Medications: Mini Bag _ ________________________________________
C. Injectable Medications: IV Push _ ___________________________________________
D. injectable Medications: IM/Sub Q ___________________________________________
III. Results: IV. Laboratory Number:
Pass
1
Fail
or No Penalty
2
(circle one)
Date of Laboratory: _____/_____/_____
Test Site: __________________________ Hospital: _________________________
Directions to the Clinical Examiner (CE): This report is the official record of the student’s
performance in the Simulation Laboratory Component of the CPNE. Please complete the
report as follows:
1. Before beginning the Simulation Laboratory Component:
a. Fill in item No. II. Sign each student’s paper as they rotate to you.
b. Fill in item No. IV.
2. During the student’s performance:
a.Place a check mark in the space to the right of each Critical Element that is completed
correctly, or
b.Print “Fail” OR “Term” in the space to the right of the first Critical Element that is not
completed correctly, and
c.Print “Pass” OR “Fail” in the space to the left of each Station to indicate the outcome
of station.
3. After a laboratory station has been concluded:
a.When the student passes the station, refer the student back to the Clinical Associate (CA)
for further directions.
b.When the student fails, the CE must describe the violation of the Critical Element in detail
in the space provided, and both the CE and the student must sign the form at that time.
App.G.2
Simulation Laboratory Component
The student’s performance is evaluated according to the Critical Elements listed. The
student must perform all the Critical Elements satisfactorily to pass. Should the student
violate any of the Critical Elements, the Clinical Examiner notifies the Clinical Associate
of the reason for the failure before informing the student.
Reasons for Failing the Simulation Laboratory
The student will fail the laboratory for any of the following reasons:
1. Omitting or incorrectly performing any Critical Element in the administration of
medication (intramuscular or subcutaneous, intravenous push and intravenous via
primary/secondary set up), or in the application of a wet to moist dressing.
2. Violating Asepsis.
3. Failing to complete each station within the allotted time.
4. Exiting the Simulation Laboratory component of the examination before
completion of the required stations without a valid reason.
Overriding Area of Care
Asepsis: The prevention of the introduction and/or
transfer of microorganisms.
4. Establishes a sterile field where required
Appendix G
App.G.3
Examiner Introduction: “Hello, my name is _______________. This is the Wound Protection
station. These are your supplies [examiner points to supplies]. The gauze preparation solution
is normal saline. This [pointing to model] is your patient. You have fifteen minutes to complete
this station. The time is now _____ o’clock. Tell me when you have completed all the Critical
Elements for this station.”
Time: _______________
start
_______________
end
__________Station A. Wound Management:
The management of a wound using a wet to moist dressing change.
1.Complies with established guidelines related to managing a wound
_______
_______
_______
_______
5. Packs wound by applying moist dressing to wound bed surface
_______
6. Applies a sterile dressing, without contaminating the wound
_______
_______
_______
9. Labels the dressing with the date, time, and their initials
_______
_______
“Have you completed all Critical Elements for this station?”............................................................._______
In laboratory 1, the student was allowed an uninterrupted station or allowed
to complete the station after the failure write up................................................................................._______
Critical Element Failed:______________________________________________________________
Description of student behavior relative to specific element failed:_________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Examiner Signature:_ _______________________________________________________________
Student Statement and Signature:_ ___________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
App.G.4
Examiner Introduction: “Hello, my name is _______________. This is the IV Medication station.
This is the medication order you are to complete [point to MAR]. Your patient is here [point to
the model]. The medications and supplies are here [point to supplies]. Record your flow rate
here [point to Recording Form]. You have twenty minutes to complete this station. The time is
now _____ o’clock. Tell me when you are ready for me to verify the drops per minute for the
Intravenous Mini B
Time: _______________
start
_______________
end
__________Station B. Intravenous Medications:
The administration of medications by intravenous routes using a primary/
secondary setup. This station includes the calculation of the drops per minute
and regulation for gravity flow IV medication administration.
1.Complies with the established guidelines related to medication
administration
_______
2.Selects the prescribed medication using the medication
_______
3.Identifies the patient immediately before administering the
medication by verifying two of the following pieces of patient
information
a.
b.
c.
Patient name
Date of birth
_______
4.Uses the prescribed route and/or site for administering the
medication
_______
_______
6. When IV medication is to be administered by a secondary method:
a.Records the correct flow rate in drops per minute on the
Simulation Laboratory Recording Form before administering
the medication
_______
1) feeling the surrounding skin for changes in temperature or
2) palpating the surrounding tissue for edema
_______
c.
Clears air from tubing before initiating flow
designated period of time (± 5 drops per minute)
_______
_______
7.Records the medication administered on the medication
_______
_______
_______
Appendix G
App.G.5
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
App.G.6
Examiner Introduction: “Hello, my name is _______________. This is the Injectable IV Push
Medication station. This is the medication order for this station [point to MAR]. Your patient is
here [point to the model]. The medications and supplies are here [point to supplies]. You may use
this form [point to recording form] for your calculations. You have fifteen minutes to complete
this station. It is now _____ o’clock. Tell me when you are ready for me to verify the medication
dose and when you have completed all the Critical Elements. Please do not place any syringes
in the trash can at this station.”
Time: _______________
start
_______________
end
__________Station C. Injectable Medications: IV Push
The administration of medications by Intravenous Push (IVP).
administration
_______
_______
3.Records the correct calculation of the prescribed dose on the
medication
_______
_______
information
a.
b.
c.
Patient name
Date of birth
_______
medication
_______
_______
a.Records the volume and time of medication to be administered
on the Simulation Laboratory Recording Form before
_______
b.Assesses the insertion site for dislocation, infiltration, or
other complications immediately before administering the
medication by
1) Feeling around the skin for changes in temperature.
OR
2) Palpating the surrounding tissue for edema
_______
_______
c.
Appendix G
d.
App.G.7
1) Aspirates for blood return unless contraindicated
_______
2)Flushes with prescribed solution prior to medication
administration
_______
3)Flushes with prescribed solution after medication
administration
_______
_______
_______
_______
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
App.G.8
Examiner Introduction: “Hello, my name is _______________. This is the IM/Sub Q Injectable
Medication station. This is the medication order for this station [point to MAR]. Your patient is
here [point to the model]. The medications and supplies are here [point to supplies]. You may use
this form [point to recording form] for your calculations. You have fifteen minutes to complete
this station. It is now _____ o’clock. Tell me when you are ready for me to verify your first
medication dose and the total doses and when you have completed all the Critical Elements
Time: _______________
start
_______________
end
__________Station D. Injectable Medications: IM/Sub Q:
The administration of medications by intramuscular (IM) or subcutaneous
(Sub Q) Injection.
administration
_______
_______
3.Records the correct calculation of the prescribed dose on the
medication.
_______
_______
information
a.
b.
c.
Patient name
Date of birth
_______
6. Uses the correct needle size for injections
_______
medication
_______
_______
_______
_______
_______
Appendix G
App.G.9
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
App.G.10
App.H.1
Appendix
H
Blank Student PCS Response Form
This section contains the Student PCS Response Form used during the CPNE.
Copy the form and use it when you practice
App.H.2
Appendix H
App.H.3
www.excelsior.edu
7 Columbia Circle, Albany, NY 12203-5159
telephone: 518-464-8500 • toll free: 888-647-2388 • fax: 518-464-8777
I. Student’s Name:
a. (print)____________________________________ Date: ________________
b. (sign) ____________________________________ PCS #: _______________
II. Examiner’s Name:
a. (print)_____________________________________
b. (sign) _____________________________________
III. Results of Examination (circle one): Pass
IV.Examination Setting:
(Place ✔next to RPAC)
Fail
No Penalty
(Write name of hospital test site)
___________ NPAC: _____________________________________
___________ SPAC: _____________________________________
___________ MPAC: _____________________________________
App.H.4
Appendix H
FLACC Scale
App.H.5
Age: 2 months to 3 years
Scoring
Category
0
1
2
Face
No Particular expression
or smile
Occasional grimace or frown,
withdrawn, disinterested
Frequent to constant
quivering chin, clenched jaw
Legs
Normal position or relaxed
Uneasy, restless, tense
Kicking, or legs drawn
Lying quietly, normal position,
moves easily
Squirming, shifting back
and forth, tense
Arched, rigid or jerking
No cry (awake or sleep)
Moans or whimpers;
occasional complaint
Crying steadily, screams or
sobs, frequent complaints
Content, relaxed
Reassured by occasional
touching, hugging or being
talked to, distractible
Difficult to console or comfort
Activity
Cry
Consolability
Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0 –2, which results in a
total score between zero and ten.
FLACC: A behavioral scale for scoring post-operative pain in young children. S. Merkel and Others (1997).
Pediatric Nurse 23(3), p 293 –297.
Age: 3 years and older
Faces Rating Scale. Explain to the child that each face is for a person who feels happy
because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very
happy because he doesn’t hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little
more. Face 3 hurts even more. Face 4 hurts a whole lot, but Face 5 hurts as much as
you can imagine, although you don’t have to be crying to feel this bad. Ask the child to
choose the face that best describes how he is feeling.
Originally published in Whaley, L. and Wong, D. (1985). Essentials of pediatric nursing,
(2nd ed.). St. Louis: The C.V. Mosby Company. Reprinted by permission.
Research reported in Wong, D. and Baker, C. (1988). Pain in children: Comparison
of assessment scales. Pediatric Nursing, 14(1), 9 –17.
App.H.6
Appendix H
App.H.7
App.H.8
Appendix H
App.H.9
REVISED
For use ONLY if you change Planning Phase NCP during Implementation Phase. Write new NCP below according to Planning Phase
critical elements. Thus, if you do not change your Planning Phase NCP, this page will be blank.
App.H.10
Appendix H
App.H.11
OR
OR
OR
OR
OR
OR
OR
App.H.12
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Comfort Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Irrigation
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Appendix H
App.H.13
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Oxygen Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Pain Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Patient Teaching
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
App.H.14
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Skin Assessment
___________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Wound Management
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
Appendix H
App.H.15
Other Observations
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
_ __________________________________________________________________________________
App.H.16
App.I.1
Appendix
I
Study Plan Time Analysis
Determine the amount of time you think you need to master the content presented in
this study guide. Take a few minutes and answer this question: “Compared to the time
I would spend in class and clinical for a campus-based course, how many total hours
do I think I need to complete my study plan?” Write your response here.
Hours Required =
The following exercise should help you identify time that you have available for study.
Record your daily activities over a one-week period. The most accurate way to do
this is to keep a daily log in your appointment book or planner, recording the actual
amount of time you spend eating, sleeping, commuting, working, watching television,
caring for your children, reading, and doing anything else you do. If your schedule is
regular and predictable you can fill in the time-use chart on the following page in one
sitting, referring to your appointment book or planner. After you record your activities,
you should be ready to schedule study periods around them. Devoting sufficient time
to independent self-directed learning will probably require that you identify activities
you can eliminate or minimize to allow for more study time. In the space below, write
the number of hours you think you could set aside each week for study.
Hours Required =
When considering the hours available for study each week, ask yourself:
• What time of the day am I most alert?
• Is it the same time every day?
•A
re there any one-hour or two-hour blocks of time each day that
I can dedicate to studying?
Next, divide the hours required for study by the hours available. The resulting number
equals the number of weeks you need to set aside for study.
For example, if you think you will require 100 hours of study time to complete preparation for the CPNE and you have 10 hours available for study each week, divide
100 by 10, which gives you 10 weeks. To account for the potential loss of scheduled
study time when you would not be able to study after all, for example during family
illnesses or holidays, factor in extra time to allow for such unforeseen setbacks.
_____ Hours Required ÷ _____ Hours Available = _____ Total Time for Study Plan
App.I.2
Sample Completed Time-Use Chart
Sample Completed Time-Use Chart
Time
7 am
Sunday
Monday
Tuesday
Commute
Commute
Commute
Commute
Commute
9
Rise, Eat
Work
Work
Work
Work
Work
10
Worship
Noon
"
Rise, Eat
Friday
Rise, Eat
11
Rise, Eat
Thursday
Sleep
8
Rise, Eat
Wednesday
Rise, Eat
Saturday
Sleep
Rise, Eat
"
"
"
"
"
Study
"
"
"
"
"
"
Chores
Family
"
"
"
"
"
1
"
Lunch
Lunch
Lunch
Lunch
Lunch
Lunch
2
Lunch
Work
Work
Work
Work
Work
Study
3
TV
"
"
"
"
"
"
4
Study
"
"
"
"
"
Chores
5
"
"
"
"
"
"
Family
6
Dinner
Commute
Commute
Commute
Commute
Commute
Dinner
7
Family
Dinner
Dinner
Dinner
Dinner
Dinner
Family
8
TV
Children
Children
Workout
Children
Children
Free
Free
9
"
Study
Study
Study
Study
10
"
"
"
"
"
11
Sleep
Sleep
Sleep
Sleep
Sleep
"
"
Sleep
"
Sleep
Time-Use Chart
Time-Use Chart
Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
7 am
8
9
10
11
Noon
1
2
3
4
5
6
7
8
9
10
11
App.J.1
Appendix
J
Self Assessment for the CPNE
Students who are pursuing a nursing degree at Excelsior College should have recent
experience in some aspect of health care. This self assessment tool will help you
assess your strengths and weaknesses in the competencies evaluated during the
CPNE. Prior to taking the CPNE, the student should be able to answer “yes” to all of
the aspects of the following question:
Do you feel competent and confident performing the following clinical competencies
according to the Critical Elements in your study guide?
App.J.2
Keeping in mind the Critical Elements (the behaviors that must be performed), check the
appropriate space to indicate your answer.
Clinical Competencies
Competent
yes
no
sometimes
Confident
yes
no
sometimes
1. Using clinical decision making process
a.Selection of a course of action or nursing
intervention based on
1) Theory
2) Scientific principles
3) Established protocols
4) Pertinent references
b. Verbalizes decisions to omit or modify care
2.Writing a nursing care plan using nursing diagnosis
in the Planning Phase:
a.Appropriate selection of diagnostic categories
related to the assigned Areas of Care for the
patient one must be actual
b. Writes patient outcomes
c.Writes 2 nursing interventions for each outcome
which will be performed
3. Evaluates the nursing care plan:
a. Selects one priority nursing diagnosis
b. Justifies the importance of this choice
c. Writes a related factor
d. Writes signs and symptoms
e.Writes an evaluation of progress toward
f.
g.Writes an evaluation of the effectiveness
of the nursing interventions
Revises nursing interventions if necessary
4. Using aseptic technique
a. Hand washing
b. Medical Asepsis
c. Surgical asepsis — e.g., sterile field
5. Preventing emotional jeopardy
Avoid any action or inaction which threatens
the emotional well-being of the patient or
significant other
6. Caring
a.Establishes verbal communication with patient
at beginning of implementation
b. Interacts verbally with patient during PCS
Appendix I
c.Uses language, verbal expressions, and physical
expressions that are appropriate
d.Relates in a manner that respects the value,
dignity, and culture of others
App.J.3
Competent
yes
no
Confident
sometimes
yes
no
sometimes
7. Mobility
a. Assesses mobility status
b. Moves or positions patient
c. Assists with transfer or ambulation
d. Supervises activities of ambulatory patients
e.Documents assessment, intervention
and evaluation
8. Preventing physical jeopardy
Avoids any action or inaction which threatens the
patient’s physical well-being
9. Administering medications
a. Complies with established guidelines
b. Uses the following common routes
1) Oral
2) Intramuscular
3) Subcutaneous
4) Intravenous
a) central
b) peripheral
c)Infusion methods (e.g., bolus,
intermittent infusion, piggyback,
and infusion control devices.)
5) Topical
a)Uses all other routes (e.g., ophthalmic,
otic, rectal, etc.)
10. Managing fluids
a. Oral-amount and administration
b.Parenteral-assessing and documenting flow rate,
checking IV site, discontinuing IV, etc.
c. Measurement of intake
d. Measurement of output
and evaluation
11. Performing assessments
a. Neurological
b. Respiratory
c. Abdominal
App.J.4
d. Peripheral Vascular
e.Skin
f.Documents assessment and evaluation
of findings
Competent
yes
no
sometimes
Confident
yes
no
sometimes
12. Performing irrigations
a.Complies with established guidelines
for irrigation of following:
1) Ophthalmic
2) Otic
3) Nasogastric
4) Colostomy
5) Wound
6) Vaginal
b. Selection, temperature of solution
c. Patient positioning and instillation
d.Documents assessment, intervention
and evaluation
13. Performing respiratory management
a. Assesses lungs
b. Performs respiratory hygiene
1) Deep breathing
2) Coughing
3) Mechanical devices
4) Chest percussion and vibration
5) Suctioning
a) Bulb syringe
b) Oropharyngeal
c) Nasopharyngeal
d) Tracheal
c. Oxygen saturations
and evaluation
14. Assessing vital signs
In completing this area consider such equipment as
tympanic sensor, electronic blood pressure monitors,
etc., for measuring the following:
a. Temperature
1) Oral
2) Rectal
3) Axillary
Appendix J
App.J.5
Competent
yes
no
sometimes
Confident
yes
no
sometimes
b. Pulse
1) Apical
2) Radial
c. Respiration
d. Blood pressure
e. Weight
f.
g. Level of pain
h.Document assessments
Oxygen Saturation
15. Performing enteral feeding
a. All feedings—tube, bottle, or other device
b. Intermittent tube feedings
c. Continuous tube feedings
d. Verifies location of nasogastric tube
and evaluation
16. Providing musculoskeletal management
a. Assesses level of mobility/pain with movement
b.Assesses musculoskeletal appearance for the
presence or absence of abnormalities
c. Performs active range of motion
d. Performs passive range of motion
e.Applies supportive or therapeutic devices
e.g., ace bandage, passive motion machine
f.
g. Maintains prescribed traction
h.Documents assessment, intervention
and evaluation
Applies heat or cold
17. Providing wound management
a. Dressing
b. Irrigations
c. Applying medication
and evaluation
18. Providing comfort management
a. Assesses level of comfort
b.Provide comfort measures
(see specific ones listed in study guide)
c.Documents assessment, intervention
and evaluation
App.J.6
Competent
yes
no
sometimes
Confident
yes
no
sometimes
19. Providing pain management
a. Assesses pain by:
1) Using scale
OR
2) Observing behaviors
b. Administers pain medication or reporting need
c. Provides pain relief measures
and evaluation
20. Performing drainage and specimen collection
a. Types
1) Wound
2) Nasogastric
3) Gastric
b.Documents assessment intervention
and evaluation
21. Performing oxygen management
a. Assess response to activity level
b. Observe nail beds
c. Administration techniques:
1) Mask
2) Cannula
3) Croupette
d. Measures oxygen saturation
and evaluation
22. Patient Teaching
a. Determines readiness to learn
b.Asks questions to identify specific
learning needs
c. Provides accurate information
d. Asks questions to determine understanding
e.Documents assessment, information provided
and patient’s response to information provided
App.K.1
Appendix
K
Patient Care Situation (PCS) Scoring Tool
App.K.2
Appendix K
I. Student’s Name: ____________________________________________
(print)
App.K.3
Manual B/P Completed
Medication Completed
_____________________________________________ ____________________________
(student’s signature)
(social security number)
II. Examiner’s Name:_ __________________________________________ ____________________________
(print)
(sign)
III. Results of the Examination (circle one)
PASS
FAIL
NO PENALTY
Time
IV. Description of the Examination Setting:
Exam Start: _____________________
PCS Number: (circle one)
1
Type of PCS: (circle one)
Time Added: _ __________________
Adult
Date of PCS: _______/_ _____ /_______
2
3
4
Child
5
Child, Adult Substitute
Schd End: ______________________
Actual End: _____________________
Directions to the Examiner: The PCS Scoring Tool is the official record of the student’s performance for the
Patient Care Situation (PCS) identified. Prior to meeting the student print the student’s name under section I
and complete information requested for II and IV.
______ a.Prepare the tool for scoring. Mark one star in the margin to the left of required Areas of Care; two
stars in the margin to the left of assigned selected Areas of Care.
______ b.Arrive 30 minutes prior to PCS #1 and #3 to assess the patient’s clinical status and gather all supplies.
______ c.After the PCS has been completed circle the student’s result in Section III above.
When you meet the student complete all of the following:
______ a.Orient the student to the unit. Use the Unit Orientation Guide. This is required for each PCS.
______ b. A
sk the student to sign the Student PCS Response Form and the PCS Scoring Tool. Then open to the
PCS Assignment Kardex.
______ c. Position the Kardex so the student can read along. State “Your patient for this PCS is” and point to
patient’s name, room number, age and diagnosis.
______ d.State “Your assignment for this PCS includes the following.” Begin at the top of the Kardex and point
to each area: state out loud information needed to complete the assignment. Required and selected
Areas of Care must be starred: one red star to the right for required, and two red stars for assigned
selected Areas of Care.
______ e.Orally state and write the start and end time (e.g., “It is now 07:30, PCS #1 is starting and
will end at 10:00”).
______ f.State to the student “Let me know when you are ready to listen to report from the patient’s nurse.”
If the nurse is not available you must give report. Follow the guidelines in the CE Protocols.
______ g.Reassess the patient’s room and confirm that all equipment is functional and that supplies,
medication, etc., are available.
______ h.When the student completes planning and hands you the NCP, read the Standard Statement to
confirm that planning has ended
App.K.4
Patient’s Name: _ _____________________________________________
Patient’s Room #: ______________ Patient’s Hosp #: _ ____________
Hospital: _____________________ Center: _____________________
Directions to the Examiner
If the student fails:
______ a.Document the Critical Element from the assigned or overriding Area of Care which has been
violated using objective terms. Include only those aspects of the PCS that relate specifically to the
failure of the Critical Element. If the overriding Area of Care does not have Critical Elements, write an
explanation supporting the failure.
______ b.Inform the Clinical Associate of any additional violations of Critical Elements that could have
influenced the student’s successful completion of the PCS had the PCS not been terminated.
______ c.Review the description of the failure with the student. Students must sign, acknowledging that they
read the description of the failure at this time. A student may write a counter statement at that time.
Area of Care failed: ___________________________________________________________________________
Critical Element failed:________________________________________________________________________
___________________________________________________________________________________________
Description of student behavior relative to specific element failed:_ _________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Clinical Examiner Signature:_ __________________________________________________________________
Student’s Signature (required):_________________________________________________________________
Student’s Statement (optional):_________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Appendix K
App.K.5
Criteria for Failing
A PCS is designated as failed and terminated if the student
1. omits a Critical Element without invoking Clinical Decision Making.
2. incorrectly performs any one of the Critical Elements for planning, implementation, or evaluation
3. violates an overriding Area of Care during planning, implementation, or evaluation.
4. terminates the PCS before it is completed, regardless of the reason.
5. fails to arrive for the PCS at the assigned time.
6. fails to complete the PCS within the allocated time.
The examination is designated as failed and terminated if the student
1. exhibits behavior which violates standards of ethical and professional behavior during the examination.
Criteria for Terminating a PCS Without Penalty
Students will be assigned to another patient, without penalty, if a PCS is canceled for any one of the following
reasons:
1.a change in the patient’s condition that interrupts the usual flow of nursing care or that interferes with
conducting the examination as specified.
2.a change in the environmental conditions of the setting which interrupts the usual flow of nursing care
or that interferes with conducting the examination as specified.
____ C
LINICAL DECISION MAKING: The problem solving process by which choices are made in nursing
practice. This process involves the identification of a patient problem, selection of a course of action or
nursing intervention in response to a patient situation and an evaluation of a patient’s progress that
is based on theory, scientific principles, established protocols, and information presented in pertinent
references. Clinical Decision Making as it is defined in the study guide, is demonstrated in the CPNE
during all phases of the nursing process. In the Implementation Phase clinical decisions are observed
through the implementation of Critical Elements. However, when a student makes a deliberate decision
to omit or modify a Critical Element, the reason for the omission or modification must be verbalized to
the Clinical Examiner at the time of the omission or modification. The Clinical Examiner and/or Clinical
Associate will determine the acceptability of that decision. An incorrect decision results in failure of the
Patient Care Situation.
Area of Care failed: ___________________________________________________________________________
Critical Element(s) Omitted:____________________________________________________________________
Student’s statement of reason for omission or modification for one or more Critical Elements:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
App.K.6
____ P
LANNING PHASE: The period of time in the PCS required for assessment and planning prior to initiating
nursing care, during which the student writes the nursing diagnostic labels, expected outcomes, and
nursing interventions. The CE will accept the NCP for the patient provided that the Critical Elements
listed below are met and the plan of care is congruent with the standards of nursing practice and the
medical regimen.
1.Writes a Nursing Care Plan that includes
a.Two nursing diagnostic labels selected from a list that is relevant to the
overriding, required, and selected Areas of Care designated on your PCS
Assignment Kardex, one which must be an actual patient problem
_______
b.One measurable expected patient outcome for each nursing diagnostic label
_______
c.Two nursing interventions for each nursing diagnostic label which will
move the patient toward the expected outcome and are to be carried out
during the PCS
_______
2.Records the correct flow rate in drops per minute on the Planning Phase
Nursing Care Plan page of the Student PCS Response Form when a gravity flow
administration of parenteral fluid is designated
_______
____ I MPLEMENTATION PHASE: This is the period of time during the PCS during which the student is
administering care to an assigned patient. The care given is evaluated according to the Critical Elements
listed. Unless Clinical Decision Making (CDM) is invoked, all of the Critical Elements in any Area of Care
must be performed as specified in the study guide to pass a PCS.
Time Begun: ________
____ A
SEPSIS: The prevention of the introduction and/or transfer of microorganisms. Special consideration
should be given to handwashing before and during each PCS as required by principles of asepsis. Any
time a violation of asepsis occurs, the entire PCS will be terminated and failed.
1.Washes hands in the presence of the Clinical Examiner before beginning the
Implementation Phase of each PCS
_______
2.Protects self, others, and the environment from contamination
_______
3.Protects the patient from contamination
_______
4.Disposes of contaminated material in the designated container(s)
_______
5.Establishes a sterile field when required
_______
Appendix K
App.K.7
____ C
ARING: A pattern of behaviors that pervades the nurse-patient interaction as characterized by
attentiveness to others’ experiences, the establishment of a trusting relationship with the patient
and/or significant other, and respect for the values, dignity and culture of others.
1.Establishes communication with the patient at the beginning of the
Implementation Phase by:
a. Introducing self
_______
and
b.Identifying the patient by verifying two of the following pieces of
patient information:
1)Patient name
_______
2) Date of birth
_______
3) Medical record number
_______
and
c.Explaining the purpose of the interaction
_______
or
d.Using touch with a patient who is a child or noncommunicating adult if
culturally appropriate
_______
2.Uses therapeutic communication techniques consistent with the patient’s level of
understanding to interact with the patient and significant others by:
a. Encouraging the patient’s expression of needs
_______
b. Responding to the patient’s verbal expressions
_______
c. Responding to the patient’s nonverbal expressions
_______
d. Facilitating goal-directed interactions by:
1)Explaining the nursing actions to be taken
_______
2)Asking questions to determine the patient’s response to nursing care
_______
3)Asking questions to determine the patient’s comfort level
_______
4)Focusing communication toward patient-oriented interests
_______
5)Eliciting the patient’s choices/desires in the organization of care
_______
3.Uses verbal expressions that are not overly familiar, patronizing, demeaning,
abusive, or otherwise unacceptable
_______
4.Uses physical expressions that are not overly familiar, patronizing, demeaning,
abusive, or otherwise unacceptable
_______
5. Relates in a manner that respects the values, dignity, and culture of others
_______
____ E
MOTIONAL JEOPARDY: Any action or inaction on the part of the student which threatens the emotional
well-being of the patient or significant others. This area is invoked at the discretion of the Clinical
Examiner, validated with the patient, and supported by data from the clinical situation. The entire PCS
will be terminated and failed any time the emotional well-being of the patient or significant other is
threatened.
App.K.8
____ M
OBILITY: The partial or complete assistance with positioning, transfer, and/or ambulation activities.
The patient may be in or out of bed and may or may not require supportive devices or a cast, but
requires assistance or supervision.
1.Assesses the patient for
a.Level of mobility
_______
b.Use of assistive devices
_______
c.Presence of balance abnormalities
_______
2.Moves or positions the patient by
a.Supporting the weak or injured parts of the body
_______
b.Supporting the patient’s head, shoulders, and pelvis
_______
c.Turning, lifting, or moving the patient to a different position
_______
d.Using body parts or external devices to keep the patient in the desired position _______
e.Using positioning and/or devices to reduce pressure on vulnerable
skin surfaces
_______
f.Using measures to prevent shearing of skin
_______
3.Assists with transfer or ambulation by
a.Stabilizing equipment
_______
b.Using measures to maintain the patient’s balance
_______
4.Records
a.Data related to:
1)Level of mobility
_______
2)Use of assistive devices
_______
3)Presence of balance abnormalities
_______
b.Positioning, transfer, or ambulation activities completed during the PCS
_______
c.Patient’s response to the positioning, transfer, and or ambulation activities
_______
____ P
HYSICAL JEOPARDY: Any action or inaction on the part of the student which threatens the patient’s
physical well-being. Students are accountable for the patient’s safety throughout the entire PCS. Any
time the physical safety of the assigned patient is threatened through omission, such as not reporting
a deterioration in the patient’s clinical condition, or by imminent incorrect action by the student, the
entire PCS will be terminated and failed. This Area of Care is to be invoked at the discretion of the
Clinical Examiner and supported by data from the clinical situation.
Appendix K
App.K.9
____ F
LUID MANAGEMENT: The assessment of fluid status and the administration of fluid intake enterally,
parenterally (central or peripheral) and, when designated, the measurement of intake and output.
1. Assesses the hydration status of the patient by one of the following methods
a.Checking skin turgor
_______
or
b.Inspecting the mucous membranes
_______
or
c.Palpating the anterior fontanel of a child less then 1 year of age
_______
2.For enteral fluids
a.Determines the kind of fluids to be ingested
_______
b.Administers or restricts fluids as designated
_______
3. For parenteral fluids
a. W
ithin 20 minutes after beginning the Implementation Phase
1)Verifies the accuracy of the flow rate by either
a)Counting the drops per minute currently flowing
_______
or
b)Documenting that the flow rate of the infusion control device is set at
the exact number required to deliver the prescribed volume by writing
the setting on the PCS Recording Form
2)Assesses the insertion site of peripheral, central, or implanted venous
access devices for dislocation, infiltration, or other complications by using
one of the following methods:
a)Feeling the surrounding skin for changes in temperature
or
b)Palpating the surrounding tissue for edema
_______
_______
3)Regulates the flow rate when required by either
a)Adjusting flow to within ±5 drops per minute (regular or microdrops)
of the calculated number of drops per minute
_______
or
b)Adjusting the flow rate of the infusion control device to the exact
number required to deliver the prescribed volume
_______
_______
4)Records the prescribed fluid infusing on the PCS Recording Form
b. Throughout the Implementation Phase
1) Administers the prescribed fluids
2)Administers the designated amount of fluid per hour within the following
ranges (as long as the amount of error does not place the patient in
physical jeopardy)
a) ± 25 ml per hour for a patient over 2 years
or
b) ± 10 ml per hour for a patient under 2 years
_______
_______
_______
_______
App.K.10
3)Recalculates the flow rate or adjusts the ICD setting if the physician’s
order changes
4) When the next prescribed primary IV fluid is required:
_______
a) Selects the designated fluid
_______
b)Calculates the amount of fluid to infuse per specified period of time
_______
c)Identifies the patient immediately before administering the IV solution
by verifying two of the following pieces of patient information
(1) Patient name
_______
(2) Date of birth
_______
(3) Medical record number
_______
d)Assesses the insertion site for peripheral, central, or implanted venous
access devices for dislocation, infiltration, or other complications by
using one of the following methods:
(1) Feeling the surrounding skin for changes in temperature
_______
or
(2) Palpating the surrounding tissue for edema
_______
e) Clears IV tubing of air before initiating flow
_______
f ) Regulates the flow rate by either
(1)Adjusting the flow to within ± 5 drops per minute (regular or
microdrops) of the calculated number of drops per minute
_______
or
(2)Adjusting the flow rate of the infusion control device to the exact
_______
_______
g)Records on the PCS Recording Form the new fluid being administered
5) When maintenance of an intermittent venous access device is required:
a)Assesses the insertion site of peripheral, central or implanted venous
access device for dislocation, infiltration, or other complications by
(1) Feeling the surrounding skin for changes in temperature
_______
or
(2) Palpating the surrounding tissues for edema
_______
b) Aspirate for blood return unless contraindicated
_______
c)Flushes the intermittent access device with the designated
flush solution
_______
d) Records the flush solution on the PCS Recording Form
_______
6) When a peripheral IV is to be discontinued:
a) Assesses condition of IV site
_______
b) Removes the cannula
_______
c) Applies pressure to the venipuncture site
_______
d) Applies a protective covering
_______
Appendix K
IV Vol.
Start
of PCS
App.K.11
4. When enteral and/or parenteral intake is assigned:
_______
a.Measures the amount of fluid ingested/infused
_______
b.Records fluid intake within ± 10% of the actual intake
_______
c.Records kind(s) of fluid ingested/infused
d.Records hourly intake on the PCS Recording Form within ± 10 minutes
of the designated time, when hourly intake is assigned
_______
5.When output is assigned:
a.Collects output
_______
b.Measures output during the entire PCS
_______
c.Records amount of output with ± 10% of the actual output for the PCS on the
PCS Recording Form (output from urinary retention catheters or other drainage
apparatus is not measured during the PCS unless otherwise designated)
_______
d.Records amount of hourly output of the PCS Recording form within
± 10 minutes of the designated time, when hourly output is assigned
_______
6. Records data related to:
a. Hydration status
_______
b.Condition of insertion site for peripheral, central, or implanted venous
access devices
_______
______ V
ITAL SIGNS: The measurement and recording of temperature, pulse, respirations, blood pressure,
weight, oxygen saturation, and pain level when assigned. (Pain level is not assigned in the same PCS
as Pain Management. Oxygen Saturation is not assigned as part of Vital Signs if it is assigned in either
Respiratory Assessment or Oxygen Management.)
1.Complies with established guidelines
_______
2.Obtains accurate vital signs by:
1st
2nd
a.Reading the instrument within a stated range of:
_______ _______ _______ _______
_______ _______
_______
b.Counting within a stated range of:
_______
_______
c. Reading the instrument within a stated range of:
1) ± 6 millimeters for blood pressure
_______
d.Obtaining an accurate weight, when assigned, by:
1)Balancing the scale
_______
2)Undressing the patient as necessary
_______
3)Maintaining cleanliness of the scale
_______
4)Weighing within one percent (1%) of the correct weight
_______
_______ _______ 14th Edition, July 2007
1)± 0.2 degrees for temperature
_______ e.Obtaining oxygen saturation, when assigned
_______
_______ f.Assessing the patient’s level of pain, when assigned, by
App.K.12
1)Asking an adult to rate level of pain using a 0–10 scale
_______
or
2)Asking a child to rate level of pain using a 0–5 faces scale or
_______
or
3)Using the FLACCpain assessment tool to rate level of pain for a
child ranging in age 2 months to 3 years of age
_______
or
4)Observing behaviors indicative of pain in a patient unable to rate
his or her pain (e.g., moaning grimacing, clutching, restlessness)
_______
3.Record each of the assigned vital signs on PCS Recording Form
_______
Baseline Values
T_ _________________
P_ _________________
R_ _________________
BP_ _________________
O2 Sat_ _________________
Wgt_ _________________
Pain Level_ _________________
Radial Pulses
equal Y N
____ A
BDOMINAL ASSESSMENT: The inspection, auscultation, light palpation, and measurement of the
abdomen for the presence of bowel sounds, distention, rigidity, and tenderness.
_______
2.Positions the patient to facilitate abdominal assessment
_______
3.Inspects for distention
_______
4.Auscultates for bowel sounds over all 4 quadrants
_______
5.Performs light palpation over all 4 quadrants for tenderness or rigidity,
_______
6.Measures abdominal girth, when assigned
_______
7.Records data related to
a.Distention
_______
b.Presence or absence of bowel sounds in each of the four quadrants
_______
c.Tenderness or rigidity
_______
d.Abdominal girth, when assigned
_______
Appendix K
App.K.13
____ C
OMFORT MANAGEMENT: The assessment of comfort needs and the implementation of measures
to meet those needs. (Comfort Management will not be assigned in the same PCS with Pain
Management.)
1.Assesses comfort needs by
a.Asking the patient to describe comfort needs
_______
or
b.Observing behaviors indicative of discomfort
_______
2.Provides three of the following comfort measures:
a.Assists the patient with washing face, hands, and/or vulnerable skin surfaces
_______
b.Repositions the patient or assists the patient to a different position
_______
c.Gives the patient a backrub
_______
d.Uses relaxation and/or distraction techniques
_______
e.Applies heat or cold when assigned
_______
f.Assists the patient with mouth care
_______
g.Changes or adjusts bed linens
_______
h.Administers medication(s) when assigned
_______
3.Records
a.Data related to comfort needs or discomfort
_______
b.Comfort measures implemented
_______
c.Patient response(s) to measures implemented
_______
____ D
RAINAGE AND SPECIMEN COLLECTION: The removal of body secretions by gravity or suction, by
a tube or other means, from a body cavity or wound, the care and protection of the surrounding skin
and, when assigned, specimen collection.
_______
2.When drainage collection is assigned:
a.Assesses the amount and color of drainage
_______
b.Cleans surrounding skin or tissue when assigned
_______
c.Inserts the tube into the appropriate body cavity
_______
d.When drainage is by tube:
1)Maintains or attaches tube to container
_______
2)Maintains patency of the tube
_______
3)Maintains drainage by gravity or suction apparatus
_______
e.Removes tube when assigned
_______
App.K.14
3.When specimen collection is assigned:
a.Obtains the designated specimen
_______
b.Places the specimen in the designated container or
on the designated surface
_______
c.Ensures that specimen is labeled
_______
d. Places specimen in designated area for transport
_______
4.Records data related to drainage amount and color
_______
5.Records data related to specimen collection
_______
6.Documents and/or reports disposition of specimen
_______
____ E
NTERAL FEEDING: The administration of nutrients by bottle, tube, or other device to infants, children,
or adults who require assistance with feeding. (Enteral Feeding will not be assigned with Personal
Cleanliness in an adult PCS unless it is a continuous tube feeding.)
_______
2.For all feedings:
a.Selects the prescribed feeding
_______
b.Positions the patient to promote feeding
_______
c.Delivers the prescribed feeding
_______
3.When assistance with feeding is designated:
a.Chooses an appropriate feeding device
_______
b.Burps an infant under 6 months of age periodically as necessary
_______
4.Administers the feeding at room temperature unless otherwise designated
_______
5.When intermittent tube feeding is designated:
a.Determines the amount of feeding to be administered
_______
b.Calculates the drops per minute
_______
c.Verifies location of a nasogastric tube by using one of the following methods
before initiating gastric feeding, unless contraindicated by:
1)Aspirating gastric contents
_______
or
2)Instilling 10–20 ml of air into stomach while auscultating
_______
d.Measures gastric residual before initiating feeding
_______
e.Reinstills gastric residual unless contraindicated
_______
f.Initiates the prescribed feeding with ± 30 minutes of scheduled time
_______
Appendix K
App.K.15
g.Regulates the feeding rate to be delivered within the specified time when
required by either
1)Adjusting the flow to within ± 5 drops per minute of the calculated number
of drops per minute
_______
or
2)Adjusting the flow rate of the enteral feeding pump to the exact number
required to deliver the prescribed volume
_______
6.When continuous tube feeding is designated:
a. Within twenty minutes after beginning the Implementation Phase
1)Verifies the accuracy of the flow rate by either
a)Counting the drops per minute currently flowing
_______
or
b)Documenting the flow rate setting on
the enteral feeding pump on the PCS Recording Form
_______
2)Regulates the flow rate when required by either
a)Adjusting the flow to within ± 5 drops per minute of the calculated
number of drops per minute
or
b)Adjusting the flow rate of the enteral feeding pump to the exact
1)Aspirating gastric contents
_______
or
2)Instilling 10–20 ml of air into stomach while auscultating
_______
the PCS by one of the following methods, unless contraindicated by
_______
_______
c.When measurement of gastric residual is designated:
1)Measures gastric residual
_______
2)Reinstills gastric residual unless contraindicated
_______
3)Determines the amount of feeding to be administered
_______
7.Records kind of oral feeding administered
_______
8.Records name and strength of the feeding product for a patient
receiving a tube feeding.
_______
9.Records amount of feeding administered.
_______
App.K.16
____ IRRIGATION: The introduction of fluid into and drainage from any body orifice or cavity.
1.Selects the designated solution
_______
2.Determines the appropriate temperature of the solution when necessary
_______
3.Positions the patient to facilitate irrigation
_______
4.Verifies the correct placement of the tube
_______
5.Instills the solution into the designated area
_______
6.Controls the rate of flow of the solution
_______
7.Positions the receptacle for return flow
_______
8.Records the kind of irrigating solution used
_______
9.Records the amount of irrigating solution used
_______
____ M
EDICATIONS: The administration of medications by any route: oral, intramuscular, intravenous,
subcutaneous, or other routes. (Must be completed successfully at least once during the CPNE.)
1.Complies with established guidelines related to medication administration
_______
2.Selects the prescribed medication using the hospital medication
_______
3.Measures the prescribed dosage
_______
4.Identifies the patient immediately before administering the medication
a.Patient name
_______
b.Date of birth
_______
c.Medical record number
_______
5.Uses the correct needle size for injections
_______
6.Uses the prescribed route and/or site for administering medications
_______
7.Administers the prescribed medications to the designated patient
_______
8.Administers the medication within 30 minutes of the scheduled time
_______
9.When IV medication is to be administered:
a.Records the correct flow rate in drops per minute for gravity flow or milliliters
per hour for infusion control devices (ICDs) on the PCS Recording Form before
b.Assesses the insertion site for dislocation, infiltration, or other complications
immediately before administering the medication by using one of the following
methods:
_______
_______
or
_______
_______
c.Clears air from tubing before initiating flow
Appendix K
App.K.17
d.When an intermittent venous access device is used:
1)Aspirate for blood return unless contraindicated
_______
2)Flushes with the designated solution prior to medication administration
_______
3)Flushes with the designated solution after medication administration
_______
4)Records the flush solution used on PCS Response Form
_______
e.Regulates the flow to deliver the prescribed amount in the designated period
of time (± 5 drops per minute for gravity flow or the correct ICD setting)
_______
10.Records the medications administered on the hospital MAR within 30 minutes
after administration
_______
11.Records on the PCS Recording Form data related to condition of insertion site for
peripheral, central, or implanted venous access devices
_______
____ M
USCULOSKELETAL MANAGEMENT: The assessment for appearance, level of mobility and pain with
movement for the designated extremity(ies), and the encouragement of, or assistance with, designated
exercise(s) and supportive devices for therapeutic purposes. Activities may include immobilization of one
or more extremities by continuous or intermittent traction to maintain body alignment, or the application
of wet or dry heat or cold to a body part for therapeutic purposes. The patient may have splints or other
therapeutic devices, require range of motion, or be at risk for musculoskeletal deterioration (e.g., bedrest).
a. Presence or absence of abnormalities (e.g., atrophy)
_______
b. Level of mobility
_______
c. Pain with movement
_______
2.Directs the patient to move the joints of the designated extremity(ies) through
active range of motion by including at leas one pair of the following: abduction and
adduction or flexion and extension
_______
or
a.Moving the joints of the designated extremity(ies) through range of motion
at least once by including at least one pair of the following: abduction and
adduction or flexion and extension
_______
b. Supporting the weight of the extremity(ies) at joints during range of motion
_______
_______
a. Protecting the skin surface of the body part to be treated
_______
b. Applying treatment to the designated body part
_______
c. Applying treatment at the designated temperature (approximate)
_______
d. Maintaining treatment for at least 20 minutes unless otherwise designated
_______
a. Verifying the prescribed traction weight
_______
b. Assuring that ropes are unobstructed
_______
App.K.18
c. Assuring that weights hang freely
_______
d. Positioning the patient to provide counter traction
_______
e. Maintaining the patient in correct alignment
_______
7. Records
a. Data related to
1)presence or absence of abnormalities (e.g., atrophy) of the
designated extremity(ies)
_______
2) Level of mobility of the designated extremity(ies)
_______
3) Pain with movement in the designated extremity(ies)
_______
b. Musculoskeletal measures implemented
_______
c. Patient response(s) to measures implemented
_______
____ N
EUROLOGICAL ASSESSMENT: The assessment of neurological status including level of consciousness,
equality of pupil size and reaction to light, sensorimotor responses, and palpation of the anterior fontanel
in a child under 1 year of age. (The Braden Scale is not to be assigned in the same PCS with Neurological
Assessment.)
_______
2.Assess the patient’s level of consciousness by
a.Asking specific questions to determine orientation to all of the following
1)Time
_______
2)Place
_______
3)Person
_______
or
b.Determining the patient’s ability to recognize familiar people or common
objects in the environment
_______
or
1 and 3 years of age or a noncommunicating child or adult
_______
3.Palpates the anterior fontanel of a child under 1 year of age, with the child
in an upright position, unless contraindicated
_______
4.Assesses pupillary response regarding
a.Equality of pupil size
and
b.Reaction to light
_______
_______
5.Assesses equality of the motor response in upper and lower extremities
in a responsive patient by
a.Asking the patient to
1)Use both hands to squeeze the student’s hands simultaneously
and
2)Dorsiflex or plantarflex both feet simultaneously against resistance
_______
_______
Appendix K
App.K.19
or
b.Observing musculoskeletal response(s) in a child under 3 years of age
or a noncommunicating child or adult for
1)Symmetry
_______
and
2)Movement
_______
6.Assesses the patient’s response to a noxious stimulus when the patient is
nonresponsive to verbal stimuli by applying pressure to a nailbed
_______
7.Records data related to:
a.Level of consciousness
_______
b.Assessment of fontanel
_______
c.Pupillary response
_______
d.Equality of motor response or observation of musculoskeletal response
_______
e.Response of noxious stimuli
_______
____ O
XYGEN MANAGEMENT: The assessment of oxygenation status and the administration of oxygen
or compressed air by cannula, mask, croupette, or other devices and the measurement of oxygen
saturation when assigned. (Oxygen Saturation, if assigned in Oxygen Management, will not be assigned
in the same PCS in either Vital Signs or Respiratory Assessment.)
1.Assesses the patient’s response to activity level
_______
2.Assesses oxygenation status by
a.Inspecting nailbeds for color, capillary refill, or clubbing
_______
or
b.Measuring oxygen saturation level when assigned
_______
3.Assesses skin surfaces in contact with oxygen delivery system
_______
4.Positions the patient to facilitate respiration
_______
5.Sets, adjusts, or maintains oxygen flow at designated rate (liters or percent)
_______
6.Maintains humidification of oxygen if humidification is present
_______
7.Removes articles, if present, which can produce a spark or flame from bedside area
_______
8.Applies, inserts, or maintains device to deliver oxygen, at the designated rate,
when required
_______
9.Applies and maintains instrument to measure oxygen saturation
level when assigned
_______
10.Records
a.Data related to each of the above assessment findings
1)Response to activity level
_______
2)Oxygenation status
_______
3)Condition of skin surfaces in contact with oxygen delivery system
_______
b.Oxygenation management measures implemented
_______
c.Patient response to measures implemented
_______
App.K.20
____ P
AIN MANAGEMENT: The assessment of the presence of pain and the implementation of pain relief
measures. (Not assigned in the same PCS with Comfort Management. (If Pain Management is assigned in
a PCS, Pain Level will not be assigned in the area of Care Vital Signs.)
1.Assesses the patient’s level of pain by
_______
_______
a.Asking an adult to rate level of pain using a 0–10 scale or a visual analog scale
or
b.Asking a child to rate level of pain using a 0–5 faces scale or age-appropriate
visual analog scale
or
_______
_______
or
d.Observing behaviors indicative of pain in a patient unable to rate his or her
pain (e.g., moaning, grimacing, clutching, restlessness)
_______
2.Administers pain medication(s), when assigned
_______
or
3.Reports the patient’s level of pain to the assigned staff nurse
_______
4.Provides one of the following pain relief measures
a.Repositions the patient or assists the patient to a different position
_______
b.Gives the patient a backrub
_______
c.Uses relaxation and/or distraction techniques
_______
d.Applies heat or cold when assigned
_______
5.Reassesses the patient’s level of pain by
a.Asking an adult to rate level of pain using a 0–10 scale or a visual analog scale
_______
or
b.Asking a child to rate level of pain using a 0–5 faces scale or age appropriate
visual analog scale
_______
or
_______
or
d.Observing behaviors indicative of pain in a patient unable to rate his
or her pain (e.g., moaning, grimacing, clutching, restlessness)
_______
6.Records
a.Patient’s level of pain
_______
b.Pain relief measures implemented
_______
_______
Appendix K
App.K.21
____ P
ATIENT TEACHING: The assessment of the need for teaching and provision of information to meet a
patient’s need. Patient Teaching will be assigned related to any of the Overriding, Required, or Selected
Areas of Care. In situations where it is appropriate, the teaching may be directed to the patient’s
significant other.
1.Determines the patient’s readiness to learn by
a.Assessing the patient’s motivation and ability to learn
_______
or
b.Identifying barriers to learning
_______
2.Asks questions to identify the patient’s specific learning need
_______
3.Provides accurate information that is appropriate for and consistent with
the identified learning need of the patient
_______
4.Asks questions to determine the patient’s understanding of the information
presented
_______
5.Records
a.Assessment of learning readiness
_______
b.Information provided
_______
c.Patient’s response to information provided
_______
____ P
ERIPHERAL VASCULAR ASSESSMENT: The assessment of temperature, perfusion, pulse, sensation,
and movement in patients with casts, traction, or peripheral vascular impairment. When possible, this
assessment would include a comparison of extremities.
_______
2.Compares the extremities by all of the following:
a.Palpating for the presence or absence of the most distal pulses
_______
b.Comparing the most distal corresponding palpable pulses
_______
c.Assessing perfusion of extremity(ies) by
1)Checking capillary refill
_______
or
2)Observing color
_______
d.Assessing for temperature of extremity(ies)
_______
e.Eliciting the patient’s response to tactile stimuli applied to the distal
portion of the extremity(ies)
_______
f.Assessing motor function by
1)Asking the patient to move extremity(ies)
or
or a noncommunicating adult
_______
_______
3.Records data related to bilateral comparison of extremities:
a.Presence or absence of the most distal pulses
_______
App.K.22
b.Capillary refill/color
_______
c.Temperature of extremity(ies)
_______
d.Response to tactile stimuli
_______
e.Motor function
_______
____ R
ESPIRATORY ASSESSMENT: The assessment of breath sounds and breathing patterns to determine
respiratory status. (Respiratory Assessment will not be assigned in the same PCS with Respiratory
Management. Oxygen Saturation, if assigned in Respiratory Assessment, will not be assigned in the same
PCS with either Vital Signs or Oxygen Management.)
_______
2.Positions the patient to facilitate assessment
_______
3.Assesses the patient’s respiratory status by
a.Instructing the patient specifically to breathe in and out as deeply as possible
_______
b.Auscultating breath sounds over upper and lower lobes by systematically
moving the stethoscope from side to side
_______
c.Observing breathing patterns
_______
d.Measuring oxygen saturation, when assigned
_______
4.Records data related to
a.Comparison of breath sounds bilaterally
_______
b.Abnormal breathing patterns
_______
c.Oxygen saturation, when assigned
_______
____ R
ESPIRATORY MANAGEMENT: The assessment of respiratory status and the encouragement of,
instruction about, assistance with, and the determination of the effectiveness of respiratory hygiene
activities. Respiratory hygiene activities include deep breathing, coughing, chest percussion, suctioning,
and/or the use of mechanical devices. (Respiratory Management will not be assigned in the same PCS
with Respiratory Assessment.)
_______
2.Positions the patient to facilitate respiratory hygiene activity(ies)
_______
3.Provides a receptacle to receive secretions as needed
_______
4.Assesses the patient’s respiratory status before initiating respiratory hygiene
activity(ies) by
a.Instructing the patient specifically to breathe in and out as deeply as possible
_______
b.Auscultating breath sounds over upper and lower lobes by systematically
moving the stethoscope from side to side
_______
c.Observing breathing patterns
_______
5.Directs the patient or performs in one or more respiratory hygiene activity(ies)
Appendix K
App.K.23
a.Deep breathing:
1)Instructs the patient specifically to breathe in and out as deeply as possible
_______
2)Repeats deep breathing exercise as ordered or as indicated by the patient’s
condition
_______
b.Coughing:
1)Instructs the patient specifically to breathe in and out deeply
_______
2)Instructs the patient specifically to cough forcefully
on third or fourth expiration
_______
3)Provides for splinting, while the patient is coughing, if necessary
_______
c.Mechanical devices, such as those used for inspiratory spirometry, etc.:
1)Instructs the patient specifically to use the device
_______
_______
d.Chest Percussion:
1)Claps the designated area(s) of the chest wall vigorously with
cupped hands, unless contraindicated
_______
_______
e.Suctioning:
1)When suctioning by catheter is assigned:
a)Verifies patency of the catheter
_______
b)Sets the pressure on the suction machine as designated
_______
c)Inserts the catheter before suctioning
_______
d)Rotates the catheter continuously during suctioning
_______
e)Suctions for no more then 15 seconds at a time
_______
f )Repeats as necessary to remove secretions
_______
or
2)When suctioning by bulb syringe is assigned:
a)Deflates the bulb syringe prior to insertion
_______
b)Inserts the bulb syringe into the patient’s mouth and/or nares before
suctioning
_______
c)Aspirates secretions
_______
d)Repeats as necessary to remove secretions
_______
6.Reassesses respiratory status immediately after respiratory hygiene activities
_______
7.Records
a.Bilateral breath sounds heard after treatment in comparison with those heard
initially related to each of the above assessment findings
_______
b.Abnormal breathing patterns
_______
c.Respiratory hygiene activities implemented
_______
d.Patient response to hygiene activities implemented
_______
App.K.24
____ SKIN ASSESSMENT: The assessment of vulnerable skin surfaces for adults and children.
1.Assesses, from the list below, a minimum of two vulnerable skin surfaces including
any designated area(s) for:
a.Color changes
_______
b.Integrity (e.g., lesions, rash, shear and pressure effects, skin tears)
_______
c.Temperature
_______
d.Edema
_______
e.Moisture (e.g., perspiration, incontinence, diarrhea, non intact
ostomy/drainage system)
_______
heels
_______
sacral/coccyx
_______
occiput
_______
trochanter
_______
skinfolds
_______
peri anal
_______
designated area
_______
2.Records assessment data of two vulnerable skin surfaces including any
designated area(s) related to:
a.Color changes
_______
b.Integrity (e.g., lesions, rash, shear and pressure effects, skin tears)
_______
c.Temperature
_______
d.Edema
_______
e.Moisture (e.g., perspiration, incontinence, diarrhea, non intact
ostomy/drainage system)
_______
____ W
OUND MANAGEMENT: The assessment of a wound and the implementation of measures to clean,
irrigate, and/or protect the wound and surrounding skin.
_______
2.Assesses the wound location, type, appearance, and presence
or absence of drainage
_______
3.When irrigation is designated:
a.Selects the designated solution
_______
b.Determines the appropriate temperature of the solution (approximate)
_______
c.Uses an appropriate irrigation delivery system
_______
d.Positions a receptacle for return flow
_______
e.Irrigates without contaminating the wound
_______
f.Protects the surrounding skin from contact with the drainage
_______
Appendix K
App.K.25
4.Cleanses the wound with the designated solution
_______
5.Applies the designated topical preparation
_______
6.When wound protection is required:
a.Removes the dressing without contaminating the wound
_______
b.Removes the dressing without injuring the surrounding skin
_______
c.Disposes of the dressing in the designated container
_______
d.Applies the dressing without contaminating the wound
_______
e.Secures the dressing
_______
f.Labels the dressing with the date, time, and their initials
_______
7.Records
a.Data related to wound
1)Location
_______
2)Type
_______
3)Appearance
_______
4.Presence or absence of drainage
b.Measures implemented to cleanse, irrigate, and protect the
wound and surrounding skin
_______
_______
App.K.26
____ E
VALUATION PHASE: This phase begins with data collection in planning and is an ongoing process
throughout the PCS. The student continuously reexamines the assessment data, planning diagnoses, and
implementation of nursing actions to determine the patient’s progress toward the expected outcomes.
Documentation of the data collected and nursing care provided will be accepted provided the Critical
Elements listed below are met and the patient’s physical and emotional well-being are not jeopardized.
The student is to finalize the NCP as correct and consistent with the patient’s condition, focusing on the
priority problem at the time of the PCS.
1.Communicates nursing care provided by
a.Recording all information required by the Critical Elements for assigned Areas
of Care on the Student PCS Response Form, including any observation of the
patient’s condition that could influence subsequent care
_______
b.Reporting to the assigned staff nurse any change that indicates an
improvement or deterioration in the patient’s clinical condition
_______
_______
b.Writes the signs and symptoms (defining characteristics) for the selected
nursing diagnosis, if an actual problem
_______
c. Writes a measurable outcome
_______
and
d.Justifies the importance of choosing this as the priority nursing diagnosis
_______
3.Writes an evaluation statement regarding the patient’s progress toward
_______
4.Revises the two interventions for the selected nursing diagnosis, if necessary
_______
5.Implements the interventions prescribed on the Nursing Care Plan
_______
6.Writes an evaluation statement on the effectiveness of the nursing interventions
_______
App.L.1
Appendix
L
Excelsior College Statement On
Standard Precautions for Infection Control
Isolation and Standard Precautions
Infection Control is the responsibility of all health care personnel. Care providers
must accept the responsibility to practice Standard Precautions and comply with
infection control practices, including isolation procedures, prescribed by the facility
in which they are delivering care. The Hospital Infection Control Practices Advisory
Committee (HICPAC) of the Centers for Disease Control presented new guidelines for
isolation precautions in 1996. The guidelines have two tiers: standard precautions and
transmission-based precautions.
Excelsior College nursing students who are providing care while taking the CPNE are
mandated to follow these infection control measures.
Go to www.excelsior.edu/CPNEapplication then click on the “Required Documents”
tab to find the “Independent Study Module for Infection Control Practices.”
App.L.2
App.M.1
Appendix
M
Reasonable Accommodations
for Students with Disabilities
Policy # 121303
Statement of Policy
Excelsior College is committed to the principle that every individual should have an
equal opportunity to enroll in Excelsior College, to demonstrate his or her knowledge
and skills under appropriate testing conditions, and to complete a degree. Excelsior
College seeks to assure access by providing reasonable accommodations to all
individuals with physical, mental, or learning disabilities recognized under the
Americans with Disabilities Act.
Federal Law defines a disability as “any mental or physical condition that substantially
limits an individual’s ability to perform one or more major life activities.” Disabilities
include physical, mental, or learning disabilities that are either chronic or temporary
in nature.
Individuals requesting reasonable accommodations must submit a request in writing
to the College. The request must be accompanied by documentation of the disability,
which must address the diagnosis (disability), prognosis (chronic or temporary and
if temporary, anticipated duration), functional limitations, and recommendations of
appropriate accommodation(s).
Procedures
Excelsior College has prepared a Disability Services Student Information Packet
which is available by calling toll free 888-647-2388 (at the automated greeting press
1-1-8631). Students may also access this information by visiting www.excelsior.
edu/disability_services to view and download instructions and forms.
Students are encouraged to request reasonable accommodations at the time they
enroll in Excelsior College. Prospective students are also encouraged to request a
Disability Services Student Information Packet as they consider enrollment in an
Excelsior College degree program. Individuals who are not enrolled and who plan to
take Excelsior College Examinations may submit their accommodation request and
documentation at the time of exam registration. Please refer to the Disability Services
Student Information Packet for complete information and directions.
App.M.2
Reasonable Accommodation(s)
Reasonable accommodation is the provision of aids, or modification to testing or
program, that allows access to the educational program.
A. Accommodation(s) to Educational Program
1.For all students and examinees with hearing or speach disabilities, the College
provides a TDD to facilitate telephone communication with the College.
2.For enrolled students, the appropriate faculty will consider requests for
substitution or waiver of specific degree requirements provided that
substitution or waiver does not alter the academic integrity of the degree.
3.Students with visual or print-based disabilities may benefit from texts and
resources in alternate format (e-files, enlarged print, etc.).
4.
To the extent possible, the College will maintain a barrier-free Web site.
B. Accommodation(s) to Testing
The College will modify testing conditions, provided the modification does not
compromise the validity of the examination. Examples of modifications to testing
include
1.
For computer-delivered testing:
• Additional time (double time or time and a half)
• Reader
• Recorder of answers/amanuensis
• Scheduled break for additional time
• Separate room
• Special mechanical devices (limited)
• Accessible workstations
2.
For paper-and-pencil testing:
• Additional time (double time or time and a half)
• Braille examination booklet (available for most exams)
• Large print examination booklet
• Large print answer sheet
• Reader
• Recorder of answers/amanuensis
• Scheduled break for additional time
• Separate room
• Sign language interpreter (spoken instructions only)
Appendix M
Reasonable Accommodations for Students with Disabilities
App.M.3
C. Accommodation(s) to Nursing Performance Examinations
The College will modify testing conditions, provided the modification does not
compromise the validity of the examination. All students must be able to safely
care for adult and pediatric patients.
Technical Standards are the required and essential abilities that an individual must
effectively demonstrate as an Excelsior College Associate Degree nursing student
taking the CPNE.
Excelsior College School of Nursing is committed to providing educational
opportunities to students with disabilities and is in compliance with the Americans
with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973. The
college provides reasonable accommodations based on the specifics of each case.
The CPNE tests a student’s application of the nursing process and technical
components for nursing practice in the care of adults and children in the acute care
setting. Therefore the nursing student must be able to perform the following:
• Assess, perceive and understand the condition of assigned patients;
• See, hear, smell, touch and detect subtle changes in colors;
•Communicate (both verbally and in writing) with English speaking patients and/
or family members/significant others as well as members of the health care
team, including nurses, physicians, support staff and faculty;
• Read and understand documents written in English;
•Perform diagnostic and therapeutic functions necessary for the provision of
general care and emergency treatment to the hospital patient
•Stand, sit, move and tolerate the required physical exertion necessary to meet
the demands of providing safe clinical care;
•Solve problems involving measurement, calculation, reasoning, analysis and
synthesis; and
•Perform nursing skills in the face of stressful conditions, exposure to infectious
agents and blood-borne pathogens.
Where appropriate, accommodations for the Nursing Performance Examinations
include, but are not limited to, the following
1. use of an amplified stethoscope
2. use of electronic devices for measuring vital signs
3.additional testing time, which can be extended by 30 minutes for each Patient
Care Situation in the CPNE
4. additional break time between examination components
App.M.4
5. for the CPNE, the assigned Areas of Care can be limited to 5
6. assistance with lifting and positioning of patients
7.provision of latex-free gloves in accordance with individual hospital policy
for latex-sensitive nurses
8.provision of a sign language interpreter
App.N.1
Appendix
N
Approved and Unacceptable Abbreviations
Approved Abbreviations for the CPNE
Following is a list of some of the common abbreviations frequently used in the
CPNE. For a more complete list of standard abbreviations, students should consult
fundamentals of nursing textbook or a nursing/medical dictionary.
—
s without
—
c
with
AP
apical pulse
BM
bowel movement
Ca
cancer, carcinoma
CHF
congestive heart failure
COPD
chronic obstructive
pulmonary disease
CVA
cerebrovascular accident
DSD
dry sterile dressing
Dsg,drsg dressing
IDDM
insulin dependent
diabetes mellitus
IM
intramuscular
IVP
Intravenous push
kg
kilogram
L
liter
mg,mgm milligram
ml
milliliter
NIDDM
non insulin dependent
diabetes
PERRL
pupils equal, round,
reactive to light
GM
gram
post-op
postoperative
gr
grain
pre-op
preoperative
GTTS
drops
prn
as needed, when necessary
HOB
head of bed
pt
patient
I & O
intake and output
R/t
related to
ICD
infusion control device
ROM
range of motion
ss
half
upper
stat
immediately
lower
wt
weight
s/p
Status post
App.N.2
Unacceptable Abbreviations for the CPNE
The Joint Commission of Accreditation of Healthcare Organizations (JCAHO)
recommends that the following abbreviations are unacceptable and should
not be used.*
@
at
D/C
>
greater than
qd or Qd write out daily
<
less than
qid or QID
write out four times
a day
use ml
qod or QOD
write out every
other day
PO
spell out ‘by mouth’
SQ or SC write out subQ
u
use units
HS
µg
(microgram) write out
mcg or microgram
write out at bedtime
or half strength
MSO4
write out morphine sulfate
Mg SO4
write out magnesium
sulfate
IU
cc
international units
use of zeros always use a zero before
a decimal point (0.5 ml)
never use a zero after a
whole number ( ml)
L use left
R use right
use discharge
* For a current list of unacceptable abbreviations, visit the Joint Commission on
Accreditation of Healthcare Organizations Web site at: http://www.jcaho.org.
App.O.1
Appendix
O
Additional Practice Care Plans
Three additional practice care plans have been provided for your use. Review
the information on the CPNE PCS Assignment Kardex and develop Planning and
Evaluation Phase care plans on the blank care plan forms provided in this appendix.
An answer key follows the blank care plan forms. Please remember that the care
plans provided in the answer key are only a sample of possible correct responses.
App.O.2
1
0800
0735
M
Jack Galipe
2038
9/14/36
123456
History of renal failure with kidney
transplant. Telemetry. Left AV shunt.
1005
Unstable Angine, DVT right leg
2 days ago
Veronica
√
x2
√
No BP, IVs or
bloods in left arm
NKA
√
*
√
√
D5W
√
50 ml/hr
√
*
temporal
artery
√
√
√
√
√
√
√
√
√
√
√
√
√
√
Elevate legs on one pillow
√
√
**
√
√
No added salt
**
Aqua K pad (continuous)
to right calf
at bedside
**
**
Cellcept 250 mg po 0830
Protonix 40 mg po 0830
Rapamune 4 mg po 0830
Lasix 40 mg po 0830
Potassium Chloride 40 meq po 0830
Appendix O
App.O.3
App.O.4
Appendix O
App.O.5
#1
Answer Key
Apply Aqua K pad to right calf
Tissue Perfusion, Ineffective
Peripheral (r/t venous thrombosis
as evidenced by edema and positive
demonstrate ways to maximize
tissue perfusion.
Homans sign)
Instruct pt to keep legs elevated
Phase.
Risk for impaired skin integrity
(r/t bedrest)
Reposition patient in bed
maintain intact skin
Assess skin
Phase.
#1
Answer Key
demonstrate ways to
maximize tissue perfusion
Tissue Perfusion,
Ineffective Peripheral
Venous thrombosis
Instruct Pt to keep
kegs elevated
Apply Aqua K pad to
right calf
√
Pt. kept legs elevated and
Aqua K pad on right calf.
√
Pt. stated the Aqua K pad felt
good; Pt. kept aqua K pad on
right calf during PCS.
√
Pt stated “I know my legs
need to be elevated.” Pt. legs
elevated during PCS.
Positive Homan’s sign and
pitting edema of right leg
and pain
Adequate circulation is a priority according to Maslow’s
Hierarchy of Needs. Pt. experiencing decreased perfusion
in lower extremities. Without ongoing assessment and
intervention the pt. is at high risk for alteration in
skin integrity and tissue damage. Thus healing and
hospitalization can be prolonged.
App.O.6
2
0730
Adrian Cutter
105A
4/28/22
Trach removed yesterday,
has DSD over trach site
√
x2
1000
M
15463
1:00 pm
Zenkers Diverticulus
Day of surgery
Day of surgery
tracheostomy, endoscopic Zenkers
diverticulectomy
Julie
Quinine
√
*
√
√
√
*
√
temporal
artery
√
D5.45
NS —
c 20 mEq
Potassium Chloride
100 ml/hr
√
√
√
√
√
200 ml remaining; follow
with 1000 ml D5.45 NS —
c
20 mEq Potassium Chloride
@ 100 ml/hr
√
√
√
√
√
√
1 - 2 people
x1 during PCS
**
√
√
√
ice chips
see Enteral Feeding
**
oral toothettes/lip balm
**
Synthroid 50 mcg per tube 0900
Cardarone 200 mg per tube 0900
Prednisone 10 mg per tube 0900
Vasotec 2.5 mg per tube 0900
Lopressor 25 mg per tube 0900
hold if heart rate < 60, systolic
BP < 95. Flush with 30 ml water
after each medication.
**
√
Osmolyte HN @ 65
ml/hr continuously via kangaroo
pump
Appendix O
App.O.7
App.O.8
Appendix O
App.O.9
#2
Answer Key
Risk for deficient fluid volume
Monitor IV fluid intake.
demonstrate no skin tenting
Assess hydration status.
Phase.
Impaired Physical Mobility
ambulate patient with assistance
ambulate to doorway
Assess patient’s response to
Phase.
ambulation before and after walk.
#2
Answer Key
Impaired Physical Mobility
Decreased strength
and endurance
Inability to walk
independently.
Ambulate with assistance.
Assess patient’s response
to ambulation before and
after walk.
√
After ambulating patient
to doorway, he stated “I am
doing better walking.”
√
After assessing patient
response to ambulation,
pt noted to be able to walk
further.
improve physical mobility
progressively increasing
ambulation distance.
√
Patient now able to walk to
doorway, which is furthest
walked so far.
Adequate physical mobility is a basic need according to
Maslow’s hierarchy and failure to meet it could lead to
several post-operative complications like pneumonia and
an increased length of stay for patient.
App.O.10
3
0740
Candice Jones
525
1010
Dehydration/Gastroenteritis
one day ago
0805
F
169246
6 months old
Susan
√
crib rails
x2
√
√
√
NKA
√
*
√
D5 ½ NS
—
c 10 mEq
Potassium Chloride
50 ml/hr
temporal
artery
√
√
√
√
√
√
√
√
*
Infant seat or hold in arms
x1 during PCS
ice chips
√
**
√
Breast feed ad lib, no solid foods
**
**
**
√
A&D
ointment to rash in diaper
area —
c each diaper change
Appendix O
App.O.11
App.O.12
Appendix O
App.O.13
#3
Answer Key
Allow for breast feeding episodes
Comfort, impaired
have fewer episodes of crying
ad lib
Hold infant.
Phase.
Impaired skin integrity
demonstrate decrease in rectal
and buttock area redness
Check diaper for urine and
loose stools
Apply A & D ointment
Phase.
with diaper change.
#3
Answer Key
Impaired Skin Integrity
frequent loose stools
demonstrate decrease
in rectal and buttock
area redness
Apply A & D ointment
with diaper change.
Check diaper frequently
for urine and loose stool
√
Patient’s skin is less red.
Excoriated areas on buttocks
√
Baby’s buttocks appearance
changed from dark red to
pale pink after two diaper
changes.
√
A & D application resulted
in baby’s skin appearing
less inflamed after two
diaper changes.
Intact skin is the body’s 1st line of defense against
infection. Restoring skin integrity will increase the
child’s comfort and prevent complications such as
infection.
App.O.14
App.P.1
Appendix
P
State Board Application Process
Entry into the practice of nursing in the United States and its territories is regulated
by the licensing authorities within each state (jurisdiction). To ensure protection of the
public’s health, each jurisdiction requires a candidate to meet the eligibility requirements identified by the state. One of these is to pass a national examination that
measures the competencies required to practice safely and effectively as a newly
licensed, entry-level registered nurse.
The National Council of State Boards of Nursing, Inc. (NCSBN) develops the
licensure examination, NCLEX-RN®, which is used by state and territorial boards of
nursing to assist in making licensure decisions. For information on the NCLEX-RN® go
to www.ncsbn.org and click on “Resources.” Under the “Resources” category, follow
the prompts for the NCLEX-RN® Test Plan. The test plan is updated every three years.
It is your responsibility to obtain licensure eligibility information from the board of
nursing in the state where you want to practice.
Application for RN licensure is a three-part process that entails:
• Application to your state board of nursing.
• Registration with Pearson VUE to take the NCLEX–RN®.
•Verification of degree completion from Excelsior College to be sent
to your Board of Nursing.
The following NCLEX-RN® Application and Graduation Processing Timeline and list
of Frequently Asked Questions will assist you in completing your state board application and NCLEX-RN® registration. You will find more detailed information about state
board processing and the licensure examination in the The State Board Booklet: Guide
to Becoming an RN, available on our Web site at www.excelsior.edu.
App.P.2
NCLEX-RN® Application and Graduation Processing Timeline
It will take four to six weeks after completion of both the CPNE and all general
education requirements to process your academic records for graduation. There are
steps you may take now to make the graduation, licensure application, and NCLEX-RN®
application processes go smoothly.
Approximately 1-3 months before you complete your last requirement:
•Download the examination application from your state board Web site linked
from www.ncsbn.org or call the state board and request the examination
application packet be mailed to you.
•Additional instructions for completing the application are found in the
State Board Booklet: Guide to Becoming an RN located on the EC Web site,
www.excelsior.edu.
•If you have questions about completing the application, call your state board or
the Excelsior College State Board Advising Team, 888-647-2388 (press 1-3-1-5 at
the automated greeting), or email [email protected].
After you complete your last program requirement:
• Apply to the state board of nursing directly, or if indicated on the application,
send the examination application to Excelsior College for processing to the
attention of the State Board Advisor.
Within 4– 6 weeks after completing your last program requirement, you are designated as “officially complete.” Once you are designated as officially complete:
•You will receive the graduation packet, including a voucher for a free transcript
and a transcript request form. Please note that if you order a transcript from our
web site, you will be charged the transcript fee. Excelsior College will send official
verification of program completion or graduation, including your transcript, to
your state board. Any requests for verification or transcripts must be made in
writing, including your signature, to Excelsior College.
•Official verifications and/or letters of qualification signed by the Dean are
processed by the State Board Advising Team within 10 business days after your
official completion date.
•You may register to take the NCLEX-RN® at Pearson VUE. Information about
NCLEX-RN® registration may be obtained at www.vue.com/nclex. The
Excelsior College NCLEX Code for the Associate Degree in Nursing is 03-419.
Approximately 2–4 weeks after program completion and/or graduation:
•Your state board will process your application and Pearson VUE will contact you
by email or mail and issue your Authorization to Test (ATT) letter. You may not
schedule to take the examination until you receive the ATT letter.
Appendix P
State Board Information
App.P.3
should I begin the process of applying for RN licensure to my
Q: How
state board of nursing?
Frequently Asked Questions
Obtain the licensure application one to two months prior to your scheduled CPNE
test date and/or completion of your last general education requirement. Read
the instructions for completing the application carefully because it is important
to know what documentation your state board of nursing requires.
Q:
Where do I get the licensure application information?
You can obtain licensure application information from the Web site of your board
of nursing. You will find Web sites and phone numbers for all boards of nursing on
the National Council of State Boards of Nursing Web site at www.ncsbn.org.
Q:
When do I apply for RN licensure to my state board of nursing?
You can begin the application process after completing your last program
requirement. General requirements for each state include an application and
fee. Some states also require a criminal background check, photograph, and
notarized signature.
Q:
What if I have questions about the application processing
or graduation timeline?
Detailed information about the licensure application and graduation processes is
located in the The State Board Booklet: Guide to Becoming an RN. You may obtain the
booklet on our Web site at www.excelsior.edu under “MyEC” or by contacting the
Excelsior College State Board Advising Team at 888-647-2388; press 1-3-1-5 at
the automated greeting, or via email at [email protected].
Q:
What if the dean of nursing has to sign my application?
If your state requires a signature by our Dean of Nursing, send the appropriate
application materials to the attention of the State Board Advising Team at
Excelsior College.
App.P.4
Q:
When will I receive official notification of program completion?
You will receive official notification of program completion approximately 4 to 6
weeks after completing all degree requirements. You will see official dates of your
degree completion and graduation on our Web site at www.excelsior.edu.
You will receive the graduation packet by mail, once your official dates of completion and graduation are posted on our Web site. The packet includes important
information along with a voucher for a free transcript and a transcript request form.
Excelsior College requires a written request, with your signature, before sending
any documentation to your state board of nursing.
Q:
When do I register for the NCLEX-RN® with Pearson VUE and pay the
registration fee?
Once you receive your graduation packet from Excelsior College, indicating that
you have officially completed the program, you may register with Pearson VUE
to take the licensure examination at www.vue.com/nclex.
You may register to take the NCLEX-RN® at Pearson VUE. Information about
NCLEX-RN® registration may be obtained at www.vue.com/nclex or by phone
at 866-496-2539. To register, you will need the Excelsior College NCLEX Code
for the Associate Degree in Nursing, which is 03-419.
Q:
When will I receive the Authorization to Test (ATT) letter needed
to schedule a test date with Pearson VUE?
You will receive the ATT letter after your board of nursing sends authorization
to Pearson VUE.
Q:
How do I know if I can work in my state as a graduate nurse before
obtaining licensure?
Some state boards of nursing allow candidates for licensure to work as graduate
nurses on a temporary basis until RN licensure is obtained. It is important to contact your board of nursing to see if this is an option in your state.
Q:
Where do I find information about NCLEX preparation materials?
For information about NCLEX-RN® preparation resources is included in the
State Board Booklet: Guide to Becoming an RN located on the EC Web site
at www.excelsior.edu.
related to management IV.G.i–IV.G.6.f
respiratory assessment IV.F.4.a–d
respiratory management IV.G.5.a–n
skin assessment IV.F.5.a–c
wound management IV.G.6.a–f
Index
A
Abbreviations
approved App.N.1
unacceptable App.N.2
Academic Honesty App.C.1–2
expected student behavior II.A.8–9
procedures App.C.1–2
statement of policy App.C.1
violation of II.A.8, II.B.2
Accommodations for disabilities II.C.5–6, IV.D.1.b,
App.M.1–4
advisement calls, CPNE I.B.2
Appeal process II.B.11
Application, CPNE
components of completed application II.B.10
confidentiality statement IV.D.2.b6
photograph and signature comparison II.A.9
policies II.C.1–7
repeat application III.B.10–11
Area(s) of Care
Overriding IVI, IV.D.1–5.d, App.A.1
asepsis IV.D.1.a–g, IV.J.1, IV.J.2.g
caring IV.D.2.a–f
definition App.A.4
emotional jeopardy IV.D.3.a–c
mobility IV.D.4.a–h
physical jeopardy IV.D.5.a–d
Required II.B.5, IVI, IV.D.1.b, IV.E.1, App.A.1,
App.A.5, App.K.9
fluid management IV.E.1.a–t
vital signs IV.E.2.a–h
Selected IVI, IV.D.1.b, IV.E.1.
abdominal assessment IV.F.1.a–f
comfort management IV.G.1.a–f
drainage and specimen collection IV.H.1.a–d
enteral feeding IV.H.2.a–j
irrigation IV.H.3.a–d
medications IV.H.4.a–o
musculoskeletal management IV.G.23.a–j
neurological assessment IV.F.2.a–g
oxygen management IV.G.3.a–g
pain management IV.G.4.a–h
patient teaching IV.H.5.a–h
peripheral vascular assessment IV.F.3.a–j
related to assessment IV.E.1–IV.F.5.d
1
Asepsis IV.D.1.a–g See also references
failure due to violation of I.B.2, App.G.2
B
background nursing content
learning resources I.C.9
blank student PCS response form I.B.1, App.H.1–15
C
Calculation IV.A.14
charts II.A.8
flow rate IV.A.13–14, IV.A.23, IV.H.4.i–j
formula IV.H.4.d
IV gtts/min IV.H.4.h
medication administration IV.J.2.g, IV.J.3.a, IV.J.3.d,
IV.J.4.a, IV.J.4.d,
output IV.E.1.n
cancelling/postponing examination date II.C.4
Carpenito-Moyet’s Handbook of Nursing Diagnosis
how to use I.A.4, III.C.8, IV.A.1–3. IV.A.6–7, IV.A.9,
App.D.5
CDM. See clinical decision making
changing CPNE date II.C.4
Clinical Associate I.A.5
appeal process II.B.11–12
assignment of II.B.11
emergencies II.C.5
PCS Scoring Tool App.K.4–5
qualifications II.A.7
role of II.A.5, App.D.1
simulation laboratory component App.G.2
simulation laboratory orientation II.B.2
simulation laboratory report App.G.1
student behavior II.A.9
student orientation II.A.9
clinical decision making IV.C.1–2
Clinical Examiner
appeal process II.B.11–12
asepsis IV.D.1.a
assignment of II.B.10–11
2
assignment of II.B.10–11
Clinical Decision Making App.A.1
evaluating CDM IV.C.2
evaluation of performance I.A.5, II.A.1
evaluation phase II.B.9
hand-washing IV.D.1.b
objectivity II.A.7
Patient Care Situation (PCS) App.A.4
Patient Care Situation (PCS) Scoring Tool App.K.4–6,
App.K.8
planning phase II.B.7
qualifications II.A.7
role of II.A.6, App.D.1
simulation laboratory II.B.3
simulation laboratory component App.G.2
simulation laboratory report App.A.5, App.G.1
training of II.A.5
when designated, term App.A.5
clinical performance evaluation I.A.5
clinical practice techniques and procedures. See references
code for nursing students I.A.3–4
CPNE
accommodations for disabilities. See Accommodations
for disabilities
appeal process. See appeal process
cancelling/postponing exam date. See cancelling/
postponing examination date
changing CPNE date. See changing CPNE date
definitions App.A.1–5
emergencies II.C.5
equipment, orientation. See orientation, equipment
failure of. See failing the CPNE
individual advisement calls. See advisement calls, CPNE
information mail box I.B.2
nursing process I.A.4, I.B.3, I.C.1–2, I.C.9, II.B.3,
IV.A.1–2, IV.C.2, IV.H.5.b, App.A.1, App.A.4,
App.K.5, App.M.3
objectives I.A.5
passing the II.A.1, II.A.7, II.B.1, II.B.10, II.B.12
patient care unit, orientation. See orientation, patient care
unit
PCS rotation. See Patient Care situation (PCS), rotation
preparation for III.A.1–4
process II.B.1–12
professional dress, standards of II.A.3–4
schedule II.A.10
simulation laboratory, orientation. See orientation,
simulation laboratory
structure II.A.1–10
student behaviors, expected II.A.8–9
student orientation. See student orientation
transfer policy II.C.4
CPNE Flash Cards/CD I.B.4
CPNE online conferences
Beginning CPNE Preparation I.B.3
Documentation (500 Y) I.B.3
Nursing Care Planning (NUR 3010) I.B.3
Skills (500 S) I.B.3
CPNE Skills Bag I.B.4
CPNE Study Guide, features I.B.1
CPNE Subcommittee II.A.4
CPNE video and interactive workbook I.B.4
CPNE workshop I.B.4
Critical Elements II.A.1, II.A.5–6, II.A.10, II.B.1–3,
II.B.5, II.B.7–9, II.B.12, III.A.1–3, III.B.2–4,
III.C.2–5, III.C.7, IV.A.4, IV.A.10
abdominal assessment IV.F.1.a
asepsis IV.D.1.a
caring IV.D.2.a
comfort management IV.G.1.a–IV.J.2.h
drainage and specimen collection IV.H.1.a–b
emotional jeopardy II..B.4, IV.D.3.a–c
enteral feeding IV.H.2.a
evaluation phase, the II.B.9, III.B.3, IV.A.1, IV.I.1
fluid management IV.E.1.a
injectable medications IV.J.4.a–g
intravenous medications IV.J.2.a–h
irrigation IV.H.3.a
IV push medications IV.J.3.a–h
medications IV.H.4.a
mobility IV.D.4.a
musculoskeletal management IV.G.2.a
neurological assessment IV.F.2.a
oxygen management IV.G.3.a
pain management IV.G.4.a
patient teaching IV.H.5.a
peripheral vascular assessment IV.F.3.a
physical jeopardy IV.D.5.a–d
planning phase, the IV.A.1
respiratory assessment IV.F.4.a
respiratory management IV.G.5.a
skin assessment IV.F.5.a
timed II.B.1, II.B.9, IV.B.2, IV.E.1.g–h
vital signs IV.E.2.a
wound management IV.G.6.a, IV.J.1.a
3
D
N
Definition(s) I.B.1, IVI
clinical decision making IV.C.1
CPNE App.1, App.A.1–5
Nursing care plan(s) I.A.4–5, II.B.3–4, III.B.3, IV.A.10,
IV.E.1.e
definition App.A.2
evaluation phase II.B.9, IV.I.3, IV.I.6, IV.I.8, App.A.2
sample IV.I.11, IV.I.19, IV.I.27, IV.I.35–36
implementation phase II.B.8, IV.B.1
planning phase, the II.B.7, IV.A.1–2, IV.A.9, App.A.4
case example IV.A.6
criteria for acceptance of the IV.A.13
practice care plans App.O
Disabilities, accommodation for. See Application, CPNE:
policies
E
Electric Peer Network I.D.2
online chat, CPNE I.B.2
evaluation, clinical performance. See clinical performance
evaluation
nursing theory and clinical decision making.
See references
Excelsior College Bookstore I.D.1
O
F
online conferences. See CPNE online conferences
failing the CPNE II.B.10–II.B.11
Fees I.B.2
administrative II.C.4–5
application II.B.10
transfer II.C.4
cancellation/rescheduling II.C.4
duplicate study guide II.C.4
forfeiture II.C.5
retaking the CPNE II.B.12
Orientation II.A.7, App.1, App.D.1
equipment II.B.4, IV.G.2.d, IV.H.1.c
patient care unit II.B.2–5
sample schedule II.A.10
simulation laboratory I.B.1, II.A.9–10, II.B.1–2, IV.J.1,
App.F.1
student I.B.1, II.A.7, II.A.9, App.D.1–8
unit orientation guide App.K.3
P
G
passing the CPNE II.B.10
Graduate Resource Network I.D.2
Patient Care Situation (PCS)
Assignment Kardex App.K.3, App.K.6
abdominal assessment IV.F.1.c–d
comfort management IV.G.1.b
definition, PCS Assignment Kardex App.A.4
definition, when designated App.A.5
drainage and specimen collection IV.H.1.b–c
enteral feeding IV.H.2.c, IV.H.2.e–f
fluid management IV.E.1.d, IV.E.1.f–g, IV.E.1.k–m
irrigation IV.H.3.b
medications IV.H.4.b, IV.H.4.i–k
mobility IV.D.4.b–IV.D.4.c
mock situation III.B.4
musculoskeletal management IV.G.2.b–d
oxygen management IV.G.3.b–IV.G.3.c
pain management IV.G.4.c
peripheral vascular assessment IV.F.3.b
physical jeopardy IV.D.5.a–b
planning phase IV.A.1–3, IV.A.10, IV.A.14
respiratory management IV.G.5.g
I
Infection Control
precautions for App.1, App.L.1
L
Learning resources III.A.3, III.B.2
associate degree nursing I.B.1–4
Excelsior College I.D.1–2, III.A.2, III.C.3, III.C.5
professional I.C.1–10
Learning strategies I.B.4, III.B.1–4
library services
Excelsior College Virtual Library I.D.2
4
samples IV.A.11, IV.A.15, IV.A.17, IV.A.19
vital signs IV.E.2.b–IV.E.2.c
wound management IV.G.6.b–c
criteria for changing the patient assignment II.B.7
framework II.B.3
patient selection criteria II.B.6
response form III.B.3, IV.D.4.e, IV.E.1.k–l, IV.H.4.b
blank App.1, App.H.1
case study IV.D.1.d, IV.E.1.k
flow rate IV.E.1.g
hydration status IV.E.1.e
infusion control device IV.E.1.g
kardex II.B.8
rotation II.A.10
determination of App.D.1
student PCS response form II.B.5, II.B.9, IV.A.2,
IV.H.4.k, IV.I.1, IV.I.9, App.A.2, App.A.4
blank I.B.1
definition App.A.5
mock situation III.B.4
writing on II.B.7
Patient Selection IV.F.2.g
criteria for II.B.6
PCS Assignment, the
Assignment Kardex II.B.5
philosophy of nursing, Excelsior College I.A.1–2
planning phase IV.A.1–25. See also references
practice care plans, additional App.O.1–13
preparation for the CPNE III.A.1–4
R
references I.C.2–10
asepsis I.C.3
background nursing content I.C.9
caring I.C.3
clinical practice techniques and procedures I.C.2–3
code of ethics for nurses with interpretative statements
I.C.9
communication and culture I.C.8
drainage and specimen collection I.C.3–4
enteral feeding I.C.4
ethics and legal aspects I.C.8
fluid management I.C.4
internet resources I.C.9–10
medications I.C.5
musculoskeletal management I.C.5
nursing theory and clinical decision making I.C.2
pain management I.C.6
peipheral vascular assessment I.C.6
planning phase I.C.2
respiratory assessment I.C.7
skin assessment I.C.7
test taking and stress management I.C.9
vital signs I.C.7
women’s health I.C.8
wound management I.C.7–8
Regional Performance Assessment Centers App.B.1–2
resources
books, journals, and web sites I.C.1–10
bookstore. See Excelsior College Bookstore
Electronic Peer Network. See Electronic Peer Network
Excelsior College resources for purchase I.B.4
Graduate Peer Network. See Graduate Peer Network
LEARN team resources I.B.2
library services. See library services
S
Safety
clients and others I.A.3
patient II.A.3, IV.D.1, IV.D.4.b–c, IV.D.5.a–b, IV.D.1,
IV.G.2.d, IV.H.3.b, App.K.8
physical IV.D.5.a, App.K.8
positioning for IV.H.5.f
psychological IV.I.3
schedule, CPNE. See CPNE, schedule
self assessment App.J.1
simulation laboratory II.B.1
completing the II.B.2–3
orientation II.B.1
report II.B.1
skills bag. See CPNE Skills Bag
state board application process App.P.1
frequently asked questions App.P.3–4
NCLEX-RN® application and graduation processing
timeline App.P.2
stress and stress management I.B.1, II.B.4, III.A.1,
III.C.1–8
student orientation II.A.9–10
study plan time analysis App.I.1–2
5
T
test site(s) II.A.4. See also Regional Performance
Assessment Centers
test taking and stress management I.C.9
travel information II.A.1–2
U
universal time chart App.E.1
V
video, CPNE. See CPNE video and interactive workbook
W
Workshop, CPNE. See CPNE workshop
6

iv Study Guide for the Clinical Performance in

Transcription

Similar documents

RN-BSN Program - the UC Irvine Health Home Page

vital signs - College of San Mateo

Your hometown. Their future.

Who are we?

Corgi (welbike)

RN-to-BSN or RN-to-MSN Education

Loma Linda University School of Nursing

christmas brochure

Staff Nurses Melaney Gordon, Farley Obusan and Educator Meg

UExcel Official Content Guide for Microbiology