david's cpne notes

Dave's CPNE study guide fixed http://docs.google.com/View?docid=dd3vnpzc_309gknq35gv

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This is a step by step walkthrough of the CPNE following the paperwork associated with a pcs. It includesmnemonics for the areas of care (AOC) which originated in Rob’s material as well as a sample grid. Thisfact should be considered a commercial for Rob’s product. I have included all the trivia associated witheach issue addressed that I have collected over several months. It is by no means complete, though I wishit were, and all information contained in this document should be considered suspect until confirmed byEC. Today is October 25, 2008 and I test in early November. I am putting this together as a way of reviewfor myself and with the hope that it will benefit those who pass this way in the future. Peace, Love, & Good Happiness Stuff,

David

CPNE ASSIGNMENT KARDEX: PCS #_______Exam Start TimeImplementation Phase Start TimeScheduled pcs End Time-Note this information well. I suggest somewhere on the grid or pcsrecording form.Actual End TimeTime AddedName of ptMale or femaleAdmitting Diagnosis-Note this information well. As of this writing it is acceptable to use amedical diagnosis as a related factor in your nursing diagnosis (ND). However, it should be amedical diagnosis that is either their admitting diagnosis or possibly referenced in their medicalhistory. In the case of the latter I would suggest avoiding a non-admitting medical diagnosis inyour care plan unless you feel it is all you have and are revising your care plan to use a “RiskFor” ND as your primary ND in the evaluation phase. If you are just getting started preparingfor your CPNE this will make sense in the near future.Room NumberPt’s date of birthHospital numberAdmission date-This is pertinent information because if you were to choose to use a “Risk For”diagnosis that is related to unfamiliar surrounding or hospitalization it is required by EC thatthe pt has been hospitalized less than 24 hours. Risk for Anxiety is not a recommended ND.Surgery dateFor Information Only- this source of information is invaluable. It will contain data that mayassist you in formulating care plans, making judgments regarding Clinical Decision Making (CDM), as well as how to approach the pt in general.Surgical procedure-If there is information here obviously the pt has had a recent surgery. Thatwill provide you with context for formulating your strategy. This will be a good time to mentionthat if the pt is reporting pain, something that should be indicated to you in the ‘ForInformation Only’ area, told to you in the report you receive from the pt’s primary nurse or CE,or at least indicated by the fact you are assigned Pain Management as an AOC the appropriaterelated factor for their pain that results from a surgical procedure is ‘tissue trauma.’ A surgery orprocedure may not be held liable for the pt’s pain.Pt’s nurse-You will need this information in case you need to report any changes in the pt’scondition, request medications that you will not be giving, and to give a report to following thesuccessful completion of the PCS.

Safety: (A component of Physical Jeopardy)This area of the kardex simply lets you know of any special needs the pt has that you must be mindful of and any other issues that relate directly to pt safety. It must be understood that during the PCS all


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areas of pt safety are under scrutiny. It is a standing order that the pt’s side rails must be up andhis/her bed must be in the low position at any time the pt is not being directly attended. This is also agood time to mention that the pt’s call bell & phone must be in reach and that it is advisable to inquireabout the pt’s general comfort & specific pain any time you are going to leave the room. Themnemonic to help you remember this is SCAB (side rails up x 2, call bell/phone within reach, askcomfort/pain, bed in low position).

Mobility (overriding area of care)Mobility is also an overriding area of care just like everything else on the first page of the kardex. Thismeans these areas are assigned for every patient. There is an area at the bottom right of the PCSrecording form where you will record information related to the pt’s mobility. I will provide you witha mnemonic for the things which must be assessed, performed, & documented in that block. Theprocess for using these mnemonics is to write them on your grid in the assigned block and place acheck to the left of the item as you perform it and to the right of it when it is documented. If youhaven’t encountered a grid yet it is simply using the back of one of the forms that you are provided atthe beginning of your PCS and, while in the planning phase, drawing three lines vertically & two lineshorizontally creating 12 blocks which are each assigned an AOC so you can note what needs to bedone as well as keep track of what is completed and documented. I will make an example of whatyour blank grid may look like on the next page. It should be pointed out that the only things thatmust be performed from the kardex will be identified with a star on the line beside the item. You mayfind a star beside bedrest under mobility but there should always be a star beside side rails in thesafety area of the kardex, for example.

Fluid ManagementYou will be assigned intake & output for every pt unless the CE makes an error. If she does and one


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or both of them are not checked take it as a gift and point out, after the pcs, that I/Os were notassigned. The same would apply if you are assigned an infant as a pt, unlikely but possible, and theweigh diapers line does not have a star. Take it as a gift. There is a lot of material out there related toweighing diapers but the main variable is whether to weigh the solid stool or not. A clean diaper mustbe weighed and subtracted from the weight of the soiled diaper. Every gram that the diaper weighsover the weight of a clean diaper is reckoned as a ml of output. This is a good place to use the inquiry“What is the procedure for this process at this facility?” This phrase is handy if you become confusedabout something.More will be written concerning I/Os in the section covering the pcs recording form.

ParenteralThis section of the kardex will inform you of the solution that is hanging, if any, the Infusion Control Device setting, any subsequent non-IV med bag solutions that you may expect to hang, and if you are assigned maintenance of an intermittent access device.If you notice that the pt has a gravity flow IV then the gtts/minute must be recorded on the nursing care plan prior to handing it in to be approved by the CE before you initiate the implementation phase.

Enteral FeedingSimply notifies you of any concerns related to the pt’s oral intake.

Vital SignsNotifies you of the vital signs you will be assigned to perform.You may elect to take an apical pulse if you can’t feel a radial but will not be allowed to substitute aradial for an apical. Patricia has suggested that we palpitate the radial pulse in both wrists and choosethe one we are able to feel better. She went on to say that this is a good practice if you have a choiceof arms when obtaining a BP as well. If level of pain is assigned here it must be assessed and declared with the vital signs.The blood pressure is initially a huge undertaking. Here are some things to keep in mind.

The BP taken in the first pcs must be manual. Following your first successful BP you may usethe automated cuff.

1.

Do not take a BP in the arm with an IV. If both arms have IVs I guess the only option is to askthe CE what the procedure for this instance is at this facility.

2.

If a second BP is required during the same PCS wait at least 10 minutes and use the same arm.3.

Make sure the BP cuff is the correct size.4.

Palpitate a brachial pulse prior to placing the bell of the stethoscope on the pt’s arm to confirmthe location of the brachial pulse.

5.

Make note of the pt’s baseline systolic number and do not exceed that number by more than30mm/hg when pumping up the cuff.

6.

I suggest using the block of your grid designated for vital signs and writing down the pt’s baselinevitals to the left of the block and making space for two additional sets of vitals. This will remind youto compare the vitals and report any changes or inspire you to recheck them if there is a dramaticdifference. There is no urgency about declaring the vital signs as you have until the end of the pcs. Ifyou are assigned medications you may consider taking vitals immediately prior to administering themeds so you will be able to assess for contraindications to medications easily. That being said, if you turn your back on the prepared medications for a moment you will be failed. I am told the CE willhold them for you while you check vitals or, in the case of multiple meds, hold the ones you are not able to contend with yourself.

Selected Areas of Care Abdominal Assessment

Mnemonic: 3Ps-look, listen, feelIt is important that these steps are performed in exactly this sequence.Pee-ask the pt if they have to pee. As an aside, if they do have to get up to go pee and you are assignedambulation now is a good time to knock it out since they’re already up.

1.

Pain-ask the pt if they are experiencing any abdominal pain. 2.

Position-if there are no inhibiting factors such as pain, limited range of motion, or respiratory concerns place the pt in as supine a position as possible & elevate their knees to facilitate the abdominal assessment.

3.

Look-note any distension associated with the abdomen. I am told that if you are assigned to measure4.


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the girth of the abdomen the points to measure from and to will be explained along with the proper procedure if you ask. Usually this measurement is taken over the navel.Listen-auscultate the four abdominal quadrants listening for bowel sounds. Listen for at least one fullminute before declaring bowel sounds absent.

5.

Feel-gently palpate the four abdominal quadrants assessing for pain and rigidity.6.

Mouse says he feels a little overwhelmed to.

The box on your grid designated abdominal assessment will initially look like this.

P P P

LOOK LISTEN FEEL

As you perform the item place a check to the left of it. Write any pertinent data that you will want toremember under the item. Make a check to the right of it when it is documented in the assessment notes.

Neurological AssessmentMnemonic: LAMP

Level of Consciousness-this is assessed by determining the pt’s orientation to person, place, andtime using standard questions. It must be documented using no abbreviations or numbers. Anunresponsive pt is assessed using noxious stimuli. The only accepted noxious stimulus is a firmpinch to the nailbed. No vigorous sternal rubs or eyeball flicks allowed at the CPNE paramedicboy. See your study guide for protocols related to non-communicative and pediatric pts.

1.

Assess fontanel if pt is less than one year old. You must sit the child up to perform thisassessment. Document as flat, depressed, or bulging.

2.

Movement-performed by having the pt elevate their arms while gripping your index and middle fingers with their hands. Following that assess the movement of their lower extremities byevaluating their dorsiflex or plantarflex.

3.

PERRL-the CE will have a penlight for you. Dim the lights and place one hand along the pt’snose vertically shielding the opposite eye and assess for equality, roundness, and reactivity.

4.

All data must be recorded as a bilateral comparison. Peripheral Vascular Assessment

Mnemonic: Please Make Sure To Check Cap RefillNote that you will be assigned either upper or lower extremities and comparing findings bilaterally.

Pulses-check most distal pulses assigned extremities.1.

Movement-assess movement of most distal portion of assigned extremities. Ask them to wiggletheir fingers, toes, or stumps-whichever is applicable.

2.

Sensation-ask the pt to close their eyes. Lightly touch the most distal portion of the assignedextremities. Ask the pt to tell you which digits you are touching.

3.


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Temperature-assess the temperature of the distal portion of assigned extremities and document as warm, hot, or cool.

4.

Color & Capillary refill-only one of these needs to be assessed since both are checking the status of perfusion. It seems to me that cap refill is much easier to document than color so I suggeststicking with capillary refill.

5.

Remember that anything out of the ordinary must be reported to the primary nurse. If there was nomention of reduced capillary refill, an exceptionally warm or cool extremity, or anything else unexpected that you find you must let the primary nurse know. Also-if their skin integrity is impaired remember to glove up.

Respiratory AssessmentMnemonic: O’Pair

Oxygen saturation percentage if assigned.1.

Position-assist pt into a position to facilitate assessment. This probably means helping them situp but if that is impossible they may need to be rolled over onto their side. If they are immobileyou may need to assess their breath sounds at a location other than their back. I like their sideat the level of their elbow for the lower lobes and above their breasts for the upper lobes. I havenot seen this commented on elsewhere.

2.

Assess rhythm, accessory muscle use, and pattern (RAP) along with breath sounds. Breathsounds are documented as clear or abnormal. Simply make a show of observing the rise and fallof their chest and looking for any paradoxical movement. It is very important to listen for their breath sounds with the bell of the stethoscope directly on their skin. It is also very important tolisten to the top lobes first, compare them, then listen to the lower lobes and compare them. Ifyou neglect either of these things it is a failure.

3.

Instruct the pt to breathe as deeply as possible while assessing them.4.

Record the date ensuring that it is structured as a bilateral comparison.5.

Did I mention that I daydream in black & white?

Respiratory ManagementThis area of care will never be assigned intentionally with respiratory assessment because the initial steps of respiratory management are exactly the same as respiratory assessment. The mnemonic forrespiratory management is h-a-i-r so the block on the grid assigned to respiratory managementshould look like this.

OPAI R H A I R

Following the steps detailed in respiratory assessment above you would then do this.Hair-ask the pt or simply observe how they tolerated deep breathing.1.

Always perform deep/breathing & coughing (db/c) exercise*. This should be checked on thekardex.

2.

Incentive spirometer if assigned on the kardex. 3.

*An important thing about the db/c & incentive spirometer is how many repetitions you areassigned. Each db/c includes 3 or 4 deep breaths followed by a forced cough with the aim ofproducing something icky from their lungs to be caught in a cup or tissue so make sure and havean appropriate receptacle. I suggest gloving up for this because if the pt suddenly needsassistance and there is expectorant going everywhere and dripping all over the place you have an


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issue. Also, if the pt is in any pain ask them if they feel the exercise will exacerbate their pain and if they feel it would a CDM omitting the exercise is in order. Remember: [gel] when gloves are removed. Reassess/record-The status of their respiratory condition prior to the interventions comparedto after must be documented as well as the pt’s response to the interventions. The pt response isbest phrased as a ‘pt stated’ but may be an observation. This is true of all management AOC. An assessment AOC only requires the results of the assessment be documented. Thereare a lot of examples of appropriate documentation out there.

4.

Skin AssessmentYou may be assigned two designated areas of skin to assess. If not assigned specific areas youmay choose 2 at your own discretion. If you choose peri anal & sacral/coccyx you immediatelyfail the entire CPNE and will not be allowed to try again. The list of possible skin areas include,but are not limited to, the heels, sacral/coccyx, occiput, trochanter, skin folds, and peri anal.

Mnemonic: TIME to Check the Color of SkinTemperature-assess the temperature of pt’s skin.1.

Integrity-assess the integrity of pt’s skin. Impaired integrity includes such things aslesions, rashes, sheer & pressure effects, & skin tears.

2.

Moisture-abnormal moisture associated with perspiration, incontinence, diarrhea, or non-intact ostomy/drainage system.

3.

Edema-documented only as present or absent.4.

Color-assess the color of the pt’s skin. If it is normal document as “skin color appropriatefor ethnicity.” If there is something abnormal about the color of the skin describe it asaccurately as possible.

5.

MedicationsGet a current drug book. They make one that has information related to the appropriateteaching for the most commonly prescribed medications*. This is important because ptteaching is often assigned with medications. Looking up each med also gives you anopportunity to note any contraindications or considerations associated with any givenmedication. *Lippincott, Williams, & Wilkins Remember your labs. Give your meds just like that.Check an apical pulse if assigned Digoxin or Toprol.The little bubble stays in the lovenox. The thigh is the easiest IM injection site.The abdomen is the easiest SbQ site.Medications need to be administered within a half-hour of their scheduled time.

Mnemonic: MARS & 5 rights

MAR-using your MAR confirm the 5 rights while obtaining the med: right pt, right med, right dose, right route, and right time.

1.

Apical pulse if required/ask allergies2.

Recheck MAR to pt ID band immediately before administering medication.3.

Sign the MAR-name, initials, ECSN4.

Intravenous Medication

These are IVMBs that you are assigned to hang. Follow the same process as described abovedoing everything just as you did in the labs.It is possible that you will be asked to set the ICD for the medication. The ICD is manufacturedso it can only be set for so many ml/hr. If the IVMB is designated to run over less than an houryou must divide the 60 minutes by the number of minutes the medication is prescribed to be administered at and multiply the ml by that number. Ex: whatever med to run 75ml over 20minutes. (60 divided by 20 = 3) x 75 = 225. The pump would be set at 225ml/hr.

Comfort Management

You may find some old study material that has a ND of Impaired Comfort. The ND book EC used to


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use had that in it but the Mosby book does not. There are currently conflicting reports about whetherit is OK to use it or not. The impaired comfort ND is best avoided unless you can confirm its validity one way or another. If assigned comfort management there are a few comfort measures you may be directed to doand may only be performed if assigned. They are administering medications, application of heat orcold, and mouth care equipment. If assigned to apply a heat or cold pack remember to wrap it in atowel as a barrier between it and the pt’s skin. Normally, the hot/cold pack should stay in place nolonger than 20 minutes.If you are not assigned specific comfort measures or need to come up with one or two, you must do 3 if assigned comfort management, your choices are to assist the pt with washing their face,hands, or other vulnerable skin surface, reposition the pt, provide a back rub, use relaxation ordistraction techniques, or change/adjust their linens-the ones on their bed, not their tighty whities,boxers, or fabulous lacy thong from Victoria’s secret (what is Victoria hiding anyway). Anyway, juststrike back rub & change linens from the list unless you don’t have anything else. Time consumingand involves moving the pt. Not Good. Providing a warm cloth and helping them wash their face isquick and easy as is repositioning them yet once again. Relaxation & distraction includes TV, readingmaterial, coloring book and crayons or toys* for kids, and guided imagery in which you hypnotize thept with your melodious voice and lead them to their happy, comfortable, pain free place and introduce

them to their spirit guide or power animal-whichever shows up first (double dog dare ya’ to dothat, you’ll be a CPNE legend).The most important thing is that at least three comfort measures are offered and the comfort level of the pt is assessed prior to the interventions and once again following. If the pt refuses a comfort measure, such as when you offer to brush their teeth but also let them know they can wait until after lunch or for their wife if they prefer, you have performed your due regard. Simply document thatyou offered and they refused and why they refused.*do not even think about blowing up a glove like a balloon and giving it to a kid-risk for aspiration/choking. You will not pass go nor collect your $200.

Muskuloskeletal ManagementMuskuloskeletal Management is assigned related to designated extremities like the peripheral vascular assessment.

Mnemonic: MAP HATRMobility Status-assess the mobility of the designated extremities.1.

Abnormalities-note any abnormalities, atrophy for example, that are related to the designated extremities.

2.

Pain-ask the pt if they are experiencing any pain or increased pain with movement in the designated extremities.

3.

Hot or Cold packsAmbulationTractionRange of motion exercises

These are four interventions that may be assigned. Traction mainly consists of ensuring that theweight is correct, the weights dangle free, the ropes are not tangled, and the pt is lying straight in bed. Range of motion exercises may be either passive or active. There really isn’t much to them. There aresome videos on youtube as well as whatever other sources you have at your disposal. Now, a wordabout ambulation. You don’t have to ambulate the pt. You do have to offer to ambulate the pt. Ifyou say, “Mrs. Jones, we need to ambulate around the nurses station now” and then start untanglingher IV stuff, getting her robe out, and all that she is probably going to go with you whether she wantsto or not. In direct sales that is called a physical action close, like when the salesman hands you theshiny pen-obviously you are supposed to sign something with it. If, on the other hand, you say “Mrs.Jones, I’ve been asked to help you take a walk if you feel up to it. If you don’t feel like it now or wouldrather wait for your family to visit to get up or the physical therapist or regular nurse to help it is OK”and then shut up it is now her turn to talk and odds are she doesn’t want to drag ass around thenurses’ station because she has already seen it, there aren’t any hot guys there, she feels like crap, herhip hurts, and she just wants to chill. Think about it.


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Again, remember this is a management area. Your documentation must describe the condition priorto the interventions, the interventions, and the pt’s response to the interventions. Each point of theCE, reflected in the mnemonics, must be performed and referenced in the documentation.

Oxygen ManagementMnemonic: SOAP

Skin Assessment-assess the skin in the proximity of the pt’s oxygen delivery tubing/mask forirritation. If it is irritated you may place a barrier, such as a piece of 4x4, between the pt’s skinand the tubing or pull some water soluableointment out of your butt and smear all over the pt and the tubing -whichever works for you.

1.

Oxygen check-includes checking the pt’s O2 sat if assigned, making sure the correct deliverydevice is being used, that the oxygen tubing is kink free, and the flow rate is set correctly.

2.

Activity-assessing the pt’s response to activity related to respiratory concerns. Does the pttolerate activity without becoming fatigued or experiencing dyspnea?

3.

Position-reposition the pt, yet again, to facilitate ease & effectiveness of respirations. (sit themup, I don’t know how many times that, as a paramedic, I have run emergency traffic dispatchedon a ‘respiratory arrest’ to a nursing home so I could sit the pt up, or wipe the fresh nail polishoff that was making the pt’s O2 sat 73%, & obtain a refusal while the CNAs looked at me like Ihad resurrected mawmaw from the dead or got pissed off because they had called the family andtold them mawmaw was dying so they better get to the hospital quick. It is almost as much funas curing a ‘stroke’ with narcan after they have given pawpaw enough hydrocodone to turn anytwo average adults into drooling, slack faced, tilted zombies. I guess the inmates (they’re lockedin, aren’t they?) are easier to feed & water that way.)

4.

Again, note that this is a management area.

Pain ManagementMnemonic: PRN

Pain-assess pt’s pain using the indicated scale1.

Reposition/reminder to do something. Probably report the pts pain level to the primary nurseor request she give the pt some pain meds. Since EC students do not administer IVP meds atthe CPNE you will not be giving any pain meds unless it is PO but even at that I don’t think theyactually let the EC students handle narcs. Maybe Tylenol.

2.

Reassess-Once more, remember to document the pt’s pain level before you’re intervention, theintervention, pt response, and pt’s pain level after.

3.

Patient TeachingMnemonic: RID of ignorance

Ready to learn-is the pt ready/willing to learn1.

Identify learning needs, note what pt teaching is assigned with.2.

Did the pt understand? Provide evidence such as a pt statement that indicates the pt got it.3.

I am going to leave you on your own for wound management, drainage and specimen collection, enteral feeding, and irrigation except for some comments at the end. They rarely come up, I am told,and you are much better off studying them for yourself and working out your own approach. Next, following a brief commercial interruption, we will go over care planning and the nursing care plan form.

How many times have you expressed anxiety & disgust concerning CPNE prep or performance and some jackass has told you to try meditation? Probably a few. In light of the fact that many suggest meditationbut leave it up to the recipient of the advice to figure the rest out I thought I would run through a basic meditation practice that might be helpful.


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Find a straight back chair or a big cushion to put under your butt while you sit cross legged on thefloor. Put your hands on your knees with your finger tips lying just over your knee caps. Put yourelbows out a little and make your back straight. You can just lie down on your back but being uprightusually works out better.Don’t be concerned with what you’re mind is doing and just spend a few minutes watching what yourmind is up to from you’re unique vantage point. Listen to the pleasant, reassuring sound of yourbreathing. Now forget about what you’re mind is doing and concentrate on your breathing. Nice,slow, deep breaths in through the nose and out through the nose. Touching the roof of your mouthwith the tip of your tongue makes this feel more natural.Do that for a couple of minutes. Then do this. Pretend, just imagine, that your breath is going all theway down to right behind your belly button like there is a little pipe going there and you are just concentrating on your breath slowly coming in, settling behind your belly button, resting there, and then rising again to start over.Now this is where it gets really weird. Imagine, your imagination is a tool for you to use, that you aresurrounded by a very gentle but strong blue energy. Kind of like when the energy monster from theold Star Trek attacked except this energy is benevolent. Take a minute or three to get this imagestrong in your imagination. This energy is peace. You know it from balls to bone. Inhale this peaceand let it settle behind your belly button before you exhale. Every time you inhale see yourself in yourimagination filling with this cool blue energy until, after a little while, you are full of peace. Everytime you exhale send a little thanks and gratefulness out to the universe or God or Isis or Jesus or Buddha or Vishnu for being so cool and letting you hang out and experience life. If you enjoy that there are a lot of neat things along those lines that are very helpful and effective. Abook by this guy named Robert Bruce called Energy Work is very cool. If your path is Christian youmay also enjoy a little book by a man named Thomas Keating called Centering Prayer.

On to care plans.I guess the best way to approach this is to state some general ideas about care planning.

The nursing diagnosis (ND) should be selected based upon the assigned areas of care (AOC) if possible.The related factor (r/t) is the thing that is causing the problem referred to in the ND.The ‘as evidenced by’ (aeb) is the thing you point to and say ‘see, this is a problem.’The more simple minded these ND are the better. If they are so simple you think they must bewrong then you are probably there. Ex: Impaired Physical Mobility r/t musculoskeletal impairment aeb limited range of motion. You basically said “they can’t move around well cause they are hurt or sick, I can prove itbecause they can’t move around.”You can use a medical diagnosis as a r/t. It should be the admitting diagnosis. If you are using a‘risk for’ ND you may consider using a disease process from their medical history but I wouldn’trecommend it. You only have to write the ND, not the r/t or aeb on the patient nursing care plan in the planning phase.In the planning phase you may use one ‘risk for’ ND and one ND reflecting a real pt problem.A ‘risk for’ ND does not have an aeb because if it did it would be a real problem and notsomething the pt is at risk for.You only have to carry one of the ND over to the evaluation phase so it is common to use a fairlygeneric ‘risk for’ ND on the care plan in the planning phase. If the ND of the actual problemturns out to not be a problem then you can use the ‘risk for’ ND as a fallback position. Ex: Yousee that you are assigned pain management as an AOC. Your kardex asserts the pt has had arecent surgery and complains of pain 6 of 10 in the vicinity of the surgical site. You write AcutePain as a ND on the care plan & use “pt will report that pain management regimen relieves pain


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to a satisfactory level, 3 or less on a scale of 1-10” as an expected outcome with the interventionsof assess pt’s level of pain & report pt’s level of pain to the primary nurse for your interventions. However, the pt reports that his pain is 0. You have two options. The first is to use the genericrisk for injury ND that you wrote in block number 2 below acute pain in block number 1. Itlooks like this. ‘Risk for Injury’ with an expected outcome of “the pt will remain free frominjury” and interventions of maintain the pt’s side rails up x 2 when pt is unattended & maintainthe pt’s bed in the low position when pt is unattended. In the evaluation phase you wouldsimply have to come up with a viable reason why the pt is at risk for injury. Per JAHCO anyonewho is hospitalized is considered generally weak. If you want to be a big wus and take a chanceon pissing your CE off you can use that as your r/t but you don’t wanna be that guy. Go to theMosby book and look at ‘Injury, risk for’ and pick something out that fits your pt like impairedphysical mobility. The second option, which in my opinion is much better, is to simply write theND of Risk for Acute Pain on the evaluation phase form with a r/t of whatever the admittingdiagnosis is and carry on. You shouldn’t ever really have to use the revised care plan form. There seems to be conflicting data about how this should go so I suggest asking your CA aboutwhat is expected regarding care plan revisions during your orientation.Everything is driven by the kardex . The ND & the interventions should come directlyfrom the kardex. The r/t and aeb come from the Mosby book. You determine your ND basedon the AOC you are assigned. Like this:

AOC

_____________________

Pain Management

Respiratory Management

Muskuloskeletal Management Oxygen Management

ND

_____________________

Acute Pain

Ineffective Airway Clearance

Impaired Physical Mobility Activity Intolerance

Pain Management: There are three possible sources of pain in EC land. If the pt has had surgery it is tissuetrauma. The reason for this is that pain is not attributable to a person, treatment, or procedure in a ND. Ifthe pain is from an injury caused by a trauma it is physical injury. If it is pain from a disease process suchas arthritis or sickle cell anemia then the disease process, as long as it is the admitting diagnosis, is the r/t. Acute pain is always evidenced by the pt’s expression of pain gauged by the pain assessment tool. It should be noted that if you are assigned pain as a vital sign and the pt has reported pain recently then you may use Acute Pain as a ND even if Pain Management is not assigned as an AOC. I don’t guess you even have tohave pain assigned as a vital sign. There isn’t any reason you can’t assess it and use the ND. Respiratory Management: Honestly, the admitting diagnosis is your best r/t. If you don’t like that for somereason then retained secretions works well, especially if they have pneumonia. Excessive Mucus is good ifthey have a respiratory infection. This is a good time to point out that infection doesn’t exist in ECland. If they are being treated with antibiotics you can’t use it and if they have an infection they should bereceiving antibiotics so just forget about it and write excessive mucus. A CHF pt would have exudates inthe alveoli but, ya’know, just write CHF as a r/t if that is what they were admitted for. As for the aeb if it isan actual problem you should have some abnormal breath sounds. Remember, breath sounds are either clear or abnormal. I don’t care if you are a master medic and can hear a plural rub across the room thoselung sounds are either clear or abnormal. So…you end up with Ineffective Airway Clearance r/t CHF aebabnormal breath sounds. There is also the aeb of absent or ineffective cough but if they can’t cough crap upand there is crap in their lungs then their breath sounds will be abnormal and if they don’t have crap intheir lungs how will you know they can’t cough, unless it is a pain issue, so what is the point. Muskuloskeletal Management: OK-since you are assigned musculoskeletal management they should eitherhave or have very recently gotten over something that impaired their mobility. You are assigned


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musculoskeletal management so their musculoskeletal system must have an issue that needs managed by ahealth care professional such as yourself. That pretty much takes care of it. Really. Impaired Physical Mobility is like Mr. Fantastic from the Fantastic Four or one of those old Stretch Armstrong dolls or silly putty or a condom. It could stretch to cover anything. As it relates to musculoskeletal management,though, we see that musculoskeletal impairment is a r/t and limited range of motion is an aeb. That wouldcover anything from a broken bone to a charlie horse.If you dig into the related factors and defining characteristics of Impaired Physical Mobility you will find stuff that will provide ND for neurological deficits resulting from CVAs, blindness or hearing loss (sensoriperceptual impairments), any cardiovascular issue, arthritis, atrophy, any problems with their gait or balance (postural instability), and depression. I dare you to write impaired physical mobility r/tdepressive mood state aeb slowed movements for that sullen 14 y/o chick who is mad at her mommy and daddy and feigned a suicide attempt. Just saying.Oxygen Management: If someone needs their oxygen managed then they probably get winded pretty easy. That is the idea behind using activity intolerance as a ND connected to oxygen management. Take yourMosby book and look in the front. There you will find a list of a lot of the devils that plague the humanrace. Find COPD in the list of devils. There you will find activity intolerance at the top of the list ofsuggested ND. It provides the r/t of imbalance between oxygen supply and demand. Find activityintolerance in the index of your Mosby book and go there. We need an aeb. Our best choices are eitherexertional dyspnea or a verbal report of fatigue. OK-lets bring it together.A guy was hospitalized with COPD exacerbation. A week ago a paramedic found him lying on the groundunder his tree stand in the woods suffering from hypothermia, an exposed femur fracture, and inrespiratory arrest. The paramedic directed the firemen to place the pt on flush O2 with a NRB and toexpose the pt because his clothes were soaked with the rain that was still poring. The mist seemed almostready to freeze as it swirled slowly around the sleeping trees and gave the illusion that it was suspendingthe bright, damp leaves in mid-air as they swirled down to cover the treacherously slick hillside. The ptwas wrapped in an emergency blanket since they were several hundred yards out in the woods. They hadbeen ridden to the scene on the pt’s son’s four wheeler so they couldn’t put him in the ambulance forwarmth. The paramedic’s basic level partner went back to the truck for the traction splint. The paramedicstarted a line and run warm NS wide open, he had put a couple bags under his shirt before he left the truck. The pt had a gag reflex and, even though he initially appeared flaccid, now started fighting like a guy whowas drowning. The paramedic had thoughtfully secured his IV with cling so it wasn’t d/c by the dyingmans gyrations. He went ahead and administered 5mg of morphine while the two firemen struggled withthe old man hoping the morphine would sedate the pt as well as control his pain because the paramedicknew his next step would be to RSI the pt and it would suck to be paralyzed and in excruciating pain. Themorphine sedated the pt but he retained his gag reflex even though his respirations were desperately slow& shallow. The pt was cyanotic and flaccid. His partner returned with the traction splint and he directedthe EMT to bag the pt. The pt’s color improved from purple to light blue. As the paramedic was preparinghis succinylcholine and versed he was thinking “I hope I remembered a spare uniform back at the station,I’m muddy as hell…….sorry, I got bored with this stuff and needed a break. Well, we know that it turnedout OK cause now the pt is here at your pcs.You were assigned oxygen management. The pt’s admitting diagnosis is COPD. The O2 rate is 3lpmdelivered by a nasal canula. You are assigned O2 sat. While attempting to use the urinal the pt becameshort of breath.Based on this your care plan looks like this at the end of the evaluation phase:

Activity Intolerance

r/t COPD aeb exertional dyspnea

The pt will participate in prescribed activity without experiencing dyspnea.(from Mosby book)

1.assess pt’s response to activity (SOAP)

2.use supplemental oxygen to keep pt’soxygen saturation 90% or above or asprescribed with activity (from kardex &quoted from Mosby)


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Risk for Injury r/t impaired physical mobility (cross referenced to risk for falls, pt mobility impaired by exertional dyspnea or whatever is going on with his femur fracture.)

The pt will remain free from injury 1.pt’s side rails maintained in the up position

while pt is unattended

2.pt’s bed will remain in the low positionwhile pt is unattended

The evaluation form for this pt would go like this.Top left-ND of Activity IntoleranceUnder that the r/t of COPDUnder that the aeb exertional dyspneaUnder that goes the rationale that supports the ND you chose. It needs to contain two positive thingsthat will occur if the outcome is met or two negative things that will occur if it isn’t. Ultimately,anything that is a management AOC is a physiological need. So we write. “Being able to tolerateactivity is a physiological need. If the pt is unable to tolerate activity he will be increasinglysusceptible to respiratory complications and, since he will be precluded from participating inactivities of daily living, he will be at risk for a depressive mood state. If the pt is able to tolerateactivity without dyspnea he will be able to fully participate in his care plan and his risk for increasedrespiratory problems will be decreased. “The measurable expected patient outcome was not met. Check the unmet box. Below the box write:Pt experienced dyspnea while attempting to use urinal. Pt required frequent rest periods. Pt statedhe became short of breath just trying to sit up in his bed.Nursing Intervention #1. Effective because you performed the assessment. Below the effective blockyou checked write: Pt’s response to activity assessed. Pt becomes short of breath immediately uponattempting any activity that requires the slightest exertion.Nursing Intervention #2. Did the pt’s O2 sat go below 90%? Probably not. You provided the pt withthe oxygen. The intervention was effective. Write this below the effective block you checked; Pt wasprovided with supplemental oxygen as directed-3 liters per minute via nasal canula throughout pcs. Pt’s O2 saturation above 90% throughout PCS.

Next we will go through the pcs recording form step by step.Enteral Intake-in this box you will individually record all the liquid things and things that would become liquid at room temperature that the pt consumes and the respective amounts. You will beprovided with measuring cups or some such or maybe a chart so you will be able to know how many ml to record for each item. Ice chips* have half the volume of water so if the pt had a cup of ice chipsand the cup was 240ml you would write 120ml water on the pcs recording form in the enteral intake block(*conflicting data, confirm). Parentaral Intake-in this block you will record any fluids which enter the body through an IV, central line, etc. Items are only recorded in this block once the bag completes. This includes IVMBs. If youhang a bag of 500mg of some medication in 50ml of solution and the bag finishes before you are through with your implementation phase it is recorded in the parenteral intake block. In addition, itis wise to make a note of the amount of fluid in any bag that is hanging when you enter the room. Ifthere is 700ml left in a 1000ml bag when you begin your implementation phase and, half way through, you have to d/c it and there is 500ml left in the bag then 200ml of whatever would get written in the parenteral intake block. If you are assigned Maintenance of Intermittent Access Devicethe amount/type of flush used gets recorded in both the IAD block as well as the parenteral intake block. Output-all fluids leaving the body including emesis & stool. Just as you explained the idea ofaccounting for intake to the pt explain that you will be keeping track of their output. Ask men to use a


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urinal. Instruct women to use the ‘nuns’ hat being mindful not to put toilet tissue in the nun’s hat. Ibelieve you may simply document the fact that the pt had a bowel movement and provide the pt’sdescription of the stool as hard, normal, soft, watery, etc. Be creative & specific describing theamount, color, and contents of emesis.

Hydration Status-document the result of assessing the pt’s skin turgor which is to be checked undertheir forearm. Describe it as tenting or non-tenting. If the pt is less than one year old you mustassess their fontanel. Document it as flat, bulging,or depressed. You must sit the child up to performthis assessment. Leave their mucus membranes alone.Medications-if assigned an IVMB you will record information related to it here as well as the condition of the IV site assessment you will do prior to hanging the bag. IM, SbQ, & PO meds areonly recorded on the MAR. Check pt ID band to MAR prior every medication administration. Remember; follow the same steps as you would in the labs when administeringmedications during the pcs. You will never encounter the need to document a flush in this block.Enteral feeding-this block only gets written in if you are assigned enteral feeding. If assigned enteralfeeding the amount of feeding does not get carried up to the enteral intake block.Parenteral Fluids-this block is where much of the information from your 20 minute checks getsrecorded. The current solution is anything such as normal saline or lactated ringers that is hanging atthe start of your pcs. The ICD setting is recorded. The IV site is assessed and you will either writeedema or no edema. Ignore temperature of IV site. The new solution line is for when the old bag isbeing replaced and a new bag is being hung. Remember; if you are writing on this line you willprobably need to record how much of the previous solution was received by the pt in the parenteral intake block.If tasked to d/c an IV you must document the condition of the site. No edema, edema, or redness aregood examples of what to write here.Record the vital signs you get here. When you are ready to declare vital signs you need to circle theones you are submitting. One thing I haven’t written about yet is weighing the pt. Here is some trivia about that.

The scale must be balanced prior to weighing the pt.1.

The pt must be undressed as necessary. I don’t know what that means except they need to be intheir gown. I don’t know if forcing mawmaw to take of her robe so you can weigh her would bea failure under emotional jeopardy or if they would fail you for weighing her with the robe on. Idon’t know if a CDM being invoked because mawmaw is cold would be supported. I guess I’llask someone later.

2.

There must be a barrier between the pt and the scale. The pt’s shoes will suffice, and they willbe wearing non-skid footwear if their feet touch the floor or you will fail. Ask the CE what to useat the particular hospital you’re at for an infant.

3.

There is some rule about weighing the pt following a meal. We need to find out about that aswell.

4.

Intermittent Venous Access Device-only write in this block if you are assigned it on the kardex in the fluid management area. Note the designated flush solution. If by some chance you have to draw up a flush instead of using a pre-filled syringe then be careful not to draw up to much more than you are assigned. I heard, don’t know if it is true, that a guy was failed because he was assigned to flush with 2ml of NS and,out of habit I guess, filled the 10 ml syringe and wasn’t even given the opportunity to waste the eight beforethe CE failed him. I guess it would throw of the parenteral intake record but it seems the wasted eight,

which is actually the name of my band and, by the way, the new WASTED8 EIGHT t-shirts arebadass, anywho, as I was saying it seems the wasted eight ml could be accounted for somewhere. I alsoread the other day that someone was failed because they didn’t get the air bubble out of the pre-filled syringe prior to attempting administration. Remember to do things during your pcs just like you do in your labs-you have to aspirate prior to flushing when assigned IVAD maintenance. This brings us to mobility. Mobility is assigned for every pt and the information is recorded at the bottomleft of the pcs recording form. The mnemonic for mobility is


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MAD ATOP.Mobility StatusAbnormalities in gait/balanceDevices-these are assistive devices, including yourself, that the pt needs to ambulate.

AmbulateTurn Off LoadPositionYou must perform at least one of the four things listed above. Remember that mobility is an ever present concern that is continually evaluated by your CE. Be mindful that you support the pt’s weak or injuredareas whenever necessary as well as minimizing the possibility of pressure or shearing force negativelyaffecting the pt’s vulnerable skin surfaces.Allrighty then, there should be plenty of examples of proper documentation regarding assessment notes available because at this very moment Mark is surfing throughout the nether regions of cyber space like theSilver Surfer tweaked on meth scouring the binary systems for only the very shiniest of CPNE prep crap.I am going to make a sample grid and write a narrative of how the initial part of a pcs should go and I thinkI’ll be almost done. Cause I have a fairy fetish

Reminders*

Wash Hands

Introduce/ID Ask

comfort/pain

Glove PRN Do 20 minute

checks

Fluid Management* TurgorDrip RateO2 CheckSite check(IV,etc)I/Os

Record

IAD Maintenance?

Mobility Mobility StatusAbnormalities

Devices A?T?O?

P?

VitalsBL 1 2TPRBPWeightO2 satPain

Selected AOC Selected AOC Selected AOC Selected AOC

Selected AOC Miscellaneous & useful information

Things to document under other observations in the assessment notes.

pcs end time admitting diagnosis & other information

from ‘for information’ only area of kardex.

*your chance to be creative, make a mnemonic

pcs scenarioYou have received a report on your pt and the CE has gone over the kardex and given you a pcs overview. You sit down where you’re directed and go to work on your care plan. Looking at your kardex you matchthe assigned AOC with ND, write the expected outcomes and find interventions that are already assignedon the kardex. You double check and make sure that there is not a gravity flow IV drip running. If there is


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your probably performing your pcs in a M*A*S*H unit in S.Korea circa. 1954 and Hotlips Hullahan is yourCE. You feel asleep studying with the TV on and your CPNE date is still three weeks away.You construct the grid on the back of the pcs recording form before you hand the CE your care plan andyou become pale, cool, and diaphoretic while she is reviewing it. She hands it back to you with a sinistersneer that implies she is amazed somebody as dumb as you look made it here in the first place but you ain’tgetting any further than the pt’s door if you don’t wash your hands properly & turn the water off with thepaper towels.Actually, she smiles happily and tells you the board is green and you may proceed.You knock on the indicated door and say “staff entering.” Saunter over to the pt and introduce yourself as“an EC nursing student who will be helping to take care of them today” and your CE as someone who isevaluating you as part of your nursing program. Thank them for allowing you to help out. (?have you washed those hands?) Say something such as “It is very important that we make sure we are where we aresupposed to be. The best way for us to do that is to check our paper work to your ID band.” Do that whilesaying the pt’s name & birth date out loud and confirming the information with the pt.Ask the pt, who you will address as Mr. or Mrs., if they have been comfortable and if they are experiencing any pain associated with what they are hospitalized for. Ask them what has helped them deal with theirpain. Go ahead and assess the pain if applicable using the pain scale and, if you used reposition pt as anintervention go ahead and do that or if you wrote that you would ask the primary nurse for their pain meds let them know you will do that at first opportunity. This builds rapport and goes to caring.Explain I/Os to the pt and move their water pitcher away from them all casual like stating that if they would like a drink you will get them a nice fresh cup of water whenever they like.You must do & document on your pcs recording form certain things within 20 minutes of beginning the implementation phase. The following is a process for not only getting them done thoroughly & completelybut also incorporating other things that must be done and are best done early and while it is convenient.State that you notice the pt has an IV. (I believe you are only responsible to evaluate the assigned IV if theyhave more than one but I don’t suppose it would hurt to assess every line going into the pt’s veins.) [gel/glove] Place the back of your hand on the IV site and state out loud that there is no edema noted unless there is. If there is edema present state that the primary nurse must be notified of it ASAP andquickly complete the 20 minute checks so you can let the primary nurse know there is a problem. Afteryou have assessed the IV site [remove gloves/gel] and proceed systematically up the pt’s arm. Assess theirskin turgor under their forearm. Follow the IV tubing up to the ICD making sure it is free of kinks andthere aren’t any big air bubbles. Make sure the ICD is set at the correct flow rate. Check any other ICDs forcorrect setting and problem free tubing. While you are here go ahead and make sure their oxygen, if theyare prescribed it, is set at the correct flow rate and the right delivery device, such as a canula, is being used. Inspect the skin in proximity to the oxygen tubing. Document the information related to fluid managementon the pcs recording form. You only document the information related to the specific IV you are assigned. Make notes on your grid pertaining to the oxygen management information if you feel you need to.Be mindful of where you place your paper work. If the CE doesn’t show you the two square feet ofdesignated clean space or whatever ask where it is and put your stuff there. Don’t move it. Go to it whenyou need to write on it or reference it. Use the gel prior to getting your pencil out or touching the paper work and after you are done with them.Perform the mobility assessments and offer the interventions. You will have to put some thought into thetiming of taking vital signs and possibly some of the mobility interventions. If your pcs feels like it is notflowing and is instead all chopped up and repetitive so friggin’ what. You’re not choreographing a showyour there to get this crap done and pass.Remember to gel before you leave a room and immediately upon entering a room. This comes up whenyou have to report something to the primary nurse or get medications. Patricia says to ask the CE to getthe door coming out of the med room, nasty door knobs & all.Move on to your selected AOC & get out of the room for good as quickly as possible so you can do the evaluation paperwork and pass. Remember; SCAB. Side rails up x 2, call bell & phone within pt’s reach,ask about comfort/pain, & bed in low position every time you leave the pt’s side. Ask the pt if there isanything else you can do for them & skedaddle. While we’re talking about this I would like to mention thatit may be wise to leave that bed low, the side rails up, and the phone/call bell within reach unless you justhave to move them because you’re ambulating the pt or something. It is one less thing you can screw up. It is my sincere hope that this work proves helpful to everyone it finds. Go with God &heal.


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DavidGenerously edited by Mark & Patricia. Made possible by the Excelsior College classof 2008.

There is some more.

Conversations with Dr. AWhile sitting here in Terza, SC waiting for mawmaw to fall, Delbert’s blood sugar todrop, or pawpaw to turn blue and take a header into his oatmeal I decided to review mycorrespondences with Dr. A. She is the fabulous lady who answers all the questionssubmitted to EC about the CPNE. I decided that if I had a question about somethingone of ya’ll might as well and recording a synopsis of them would benefit allconcerned.These are the things I learned corresponding with Dr. A. that didn’t get covereddirectly in the study guide.

If using a ‘risk for’ diagnosis you may use patient teaching as an intervention.1.

If you are revising your care plan and making your priority diagnosis a ‘riskfor’ diagnosis you may wait until the evaluation phase to make the changes onyour paperwork.

2.

You may use medication the patient is taking as a r/t with a ND of ‘risk forinjury.’

3.

Asking the primary nurse to medicate the patient is not considered a comfort measure.

4.

Dr. A says “The rational statement needs to answer the following statements:1) why is this a priority problem for the patient (ie: acute pain is not a normalway of life for any person.), 2) if the problem is not addressed whatcomplications (provide examples) might occur (ie: acute pain that is notaddressed will adversely affect the patient’s ability to recover. Complications,such as DVT, upper respiratory infection, and constipation could result due toimmobility and alterations in respiratory function or GI motility.), or 3) if theproblem is addressed what positive outcomes (provide examples) would occur(ie: managing the patient’s acute pain will allow the patient to participate inthe established plan of care. When the patient is more comfortable they willbe able to ambulate and perform respiratory hygiene activities that will allowfor a recovery time that is expected and leads to their ability to return to theirusual level of functionality.)”

5.


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I had originally misread this to mean that there must be two negatives that would occur if the outcome was not meet as well as two positives associated with the outcome being met. It is one or the other but both are OK.If oxygen saturation is not assigned with oxygen management it would beacceptable to write ‘use supplemental oxygen to increase patient’s ability toparticipate in the care plan’ as an intervention.

6.

An example of acceptable documentation for mobility I submitted to Dr. A. “Pt directed to utilize a walker or be assisted when ambulating by MD. Ptstates pain localized to left knee 5 of 10 increasing with any movement. Incision above left knee result surgical procedure. Incision dressed with noindication of infection or bleeding. Pt responded to suggestion of range ofmotion exercises by stating that her level of pain would not permit it. Primarynurse notified of pt complaint of pain.

7.

Approved examples of skin assessment notes: “Pt’s epidermis inspectedproximity of occiput and sacral/coccyx. Pt’s skin was intact with full integrityboth areas. No edema or excessive moisture noted. Pt’s skin was appropriatecolor for ethnicity and warm to touch.” “Pt’s epidermis inspected proximity ofsacral/coccyx and left trochanter. Skin in the vicinity of sacral/coccyx areapink, warm, and dry. Skin in the area of the left trochanter warm and dry butreddened and showing signs of risk for developing a pressure ulcer. Noedema noted” “Pt’s epidermis inspected proximity of sacral coccyx and lefttrochanter. Skin on both areas reddened with evidence of rash. Skin on bothareas warm. No edema noted either area. Increased moisture to both regionsrelated to incontinence.”

8.

Approved abdominal assessment notes: “Pt stated that she did not need tourinate and was not experiencing any abdominal pain. Pt assisted to supineposition with knees elevated. Pt’s abdomen soft and non-tender. Bowelsounds present all four quadrants. No distension noted.” “Pt has a follycatheter. Pt states that she is experiencing abdominal pain lower rightquadrant in the proximity of surgical incision. Pt’s abdomen soft all fourquadrants and non-tender except for lower right quadrant. No distensionnoted. Bowel sounds present all four quadrants.”

9.

Sanctioned neurological: “Pt alert and orientated to person, place, and time. Pt exhibited equal strength bilaterally in handgrips and plantar flexion. PERRL.”

10.

Sanctioned oxygen management: “Pt’s skin in proximity to oxygen deliverydevice tubing inspected and found to be intact with no loss of integrity. Oxygen therapy continued at 3 liters per minute via nasal canula. Oxygensaturation 96%. Capillary refill less than three seconds. Pt ambulated tobathroom without experiencing dyspnea. Pt was positioned to facilitate easeof respiration.”

11.


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Following the commercial there is some information on enteral feeding, irrigation,and wound management.

IrrigationThe EC study guide defines irrigation as the introduction of fluid into and drainage

from any body orifice or cavity. If this comes up it will probably involve irrigating an

NG tube. I’m not that familiar with this. We have NG tubes on the truck but they are

only for an intubated pt during a cardiac arrest. Getting air out of the belly can

relieve pressure off the lungs & heart improving the chances of a positive outcome.

We’re usually at the hospital before we get to it.

OK, all I have is a mnemonic and a suggestion.

I-input/verify tube placement

R-reposition pt if necessary

R-right solution & temperature

I-instill at correct flow

G-good return flow

A-amount of solution used

IRRIGA (if you picture a little Japanese guy with round glasses yelling “IRRIGA!” and pointing up you will never forget this)

-vs-GodzillaWhatever helps to remember this stuff. Anyway, after reading over the CE the

mnemonic seems to cover it and the information about the right solution,

temperature, return receptacle, etc should all be on the kardex. If you get a deer in

the headlights look and murmur “What is the appropriate procedure for irrigation at

this facility? I’m not familiar with the equipment.” there is a good chance you will get

positive direction from your CE.

They don’t always look that mean or fight like Irigga & Godzilla.

Enteral Feeding

R-record…

A-amount of formula &

T-type of formula

F-fowlers

E-examine gastric tube & abdomen

V-verify tube placement

E-expiration date of formula

R-record

RAT FEVER


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Believe it or not, I just got nuthin to say.

Wound Management

I really want to be helpful but other than to remember that you

will be supplied with the correct equipment and given the

correct solutions and whatnot on the kardex I don’t have

anything useful. Just do it like you did in your lab, I guess. My

wife told me that when she worked on a med-surg floor she had

to do this sort of thing a lot. She said they were poking around

in wounds with q-tips and all kinds of stuff and pts would

scream horribly & cry pitifully. I think if you follow the

directions using the designated equipment and document the

where, what (type), & how (appearance) of the wound noting

the presence or absence of drainage and what it was exactly

that you did it will be OK.

Ok, this particular portion is the only part of the study guide, other than a fewedits, that I have written since passing the CPNE. I need to tell you that in myexperience the CA & CEs were fair, approachable, willing to reason with you ifyou felt you had a case, and genuinely wanted you to pass but were not, underany circumstances, going to cut you any slack. I want to tell you that this studyguide will absolutely help you pass the CPNE. The mnemonics are excellent andsimple. The recommendations for care planning are accurate. This works. Ialso think you need to know that workshops are overrated. I blew over athousand bucks on two workshops-the EC one and Lynn’s. The EC one is goodin as much as you get to meet some EC staff, ask them questions, and let themevaluate your work. Inevitably something you learn there will be contradictedlater. It is just the nature of the beast. I also attended Lynn’s workshop andspent gobs of $ on her material. Since my Mama taught me not to say anythingif I got nothing good to say I will honor her and leave it at that. Rob’s video willbe the best $40 you spend out of the thousands you invest in your program. Theabsolute best thing is to find someone who has passed the CPNE and spend a daywith them and go over care planning, the AOC, and the labs. You can e-mail [email protected] and I will answer anything I can for you.It is true that the whole CPNE is high anxiety & high stakes. I have been armyinfantry, door to door sales paid straight commission for a decade or so, a stay athome dad for four years, helped pastor some of God’s children on occasion, anda paramedic for over five years. Nothing put me in a near panic state for threedays like this did. The first few days post CPNE I exhibited classic PTSD s/s.


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Paramedic people, this is just not the same game as the national registry. On theother hand it is really very simple stuff & you can do it just fine. I don’t intendto write a journal but I do want to give an example from my experience abouthow simple the care plans can be made and also an example of how easy it is tofail a PCS. I had a pt admitted with rectal bleeding who was complaining ofabdominal pain 9 0f 10 prior to admission from the ER yesterday where she hadbeen medicated for the pain. She was now pain free. I mentioned to the CE thatthis was more like an admitting symptom as opposed to an admitting diagnosis. Iwas not assigned pain management but was assigned pain as a vital sign. Inreport I learned the pt was scheduled for endoscopy to find out what was goingon. There was blood in her last stool and there was no report of trauma. Iblanked on what to use for a related factor. I was panicking. I did what you willhave to do. Remember what you know. I went to the front of the Mosby book,the best place to go when you are confused about a care plan. I found abdominalpain on page two just like the index said it would be. I discovered there are twosources of abdominal pain per Mosby-injury & pathological process. I wrestledwith this for a long time until I had to make a decision. Rectal bleeding couldn’tbe causing the pain & there was nothing else going on with the pt so I rolled withRisk for Acute Pain r/t pathological process. Apparently that was OK Fine. However, the fact that I was so while preoccupied thinking about it performingmy AOC that I didn’t assess her lower abdominal quadrants and instead assessedthe pt’s upper quadrants twice AND got so caught up in the elation of figuring itout in the evaluation phase that I forgot to write a rationale statement cost methe pcs, prevented me from having a no repeat CPNE, put me in a do or diesecond pcs on Sunday morning, and possibly aged me several years over a fewhours. As Mark Dewy has stated; the CPNE is very easy to pass and just as easyto fail. Experience is the best teacher but it is better to learn from someone else’sexperience than your own so you would do well to take these things to heart. Theonly other specific thing I feel I should pass along from my CPNE experience isto make a list of all the contradictory & crazy things you have been told or readabout what is required and ask the CA about them during the orientation. Chances are she will clear them up for you so you can proceed with a greaterdegree of confidence. OK-back to the pre-recorded programming.

Allrighty then, other than the labs that is all I got. There is plenty of stuff out there that will help youprepare for those. The inspiration for putting thistogether was, in addition to being a review for me, theidea that it may provide others with a consolidated &


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straightforward study guide. There is a lot of goodinformation out there but sorting it out so that itworks together is tough. If I were there I would patyou on the butt and say “go get’em, you’ll be allright”and you would probably want to punch me becauseeverybody says that and you know it will not beallright until you have that ‘passed’ certificate in yourhand on Sunday morning. Stay focused & don’t giveup. Dumber people than you have done this. I wouldadd ‘Good Luck’ but a pretty smart fella told me thatluck is when preparation & opportunity meet. I thinkit was the same smart fella who taught me the 3Psrule. Poor prior planning equals piss poorperformance. So prepare as much as you are able,plan what you will do when things come up, and don’tstop planning when you get there. I think the mostimportant planning time is immediately before theimplementation phase. I think it is called the planningphase. Don’t short cut there. Take the time to build agood foundation for your pcs. Peace & Light, DavidSittin’ on the dock of the bay, wastin’ time..“Yeshua said: Be a passerby.” Gospel of Thomas 42

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