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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 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) 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: The successful student: 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: The successful student: 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Study Guide for the Clinical Performance in Nursing Examination 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. vi Study Guide for the Clinical Performance in Nursing Examination 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 Email: [email protected] • 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 Email: [email protected] 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. viii Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 CPNE Online Conference— Documentation (500 Y)........................... I.B.3 CPNE Online Conference— 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. x Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Study Guide for the Clinical Performance in Nursing Examination 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 Critical Elements for 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 Critical Elements for 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 Critical Thinking Answer Key.................IV.D.2.f 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 Critical Thinking Answer Key.................IV.D.4.f 14th Edition, July 2007 Respiratory Assessment.....................................IV.F.4.a Critical Elements for Respiratory Assessment......................... IV.F.4.a Skin Assessment................................................IV.F.5.a Critical Elements for Skin Assessment.................................... IV.F.5.a Selected Areas of Care Related to Management.........................................IV.G Comfort Management.......................................IV.G.1.a Critical Elements for Comfort Management ...........................IV.G.1.a Critical Thinking Answer Key................IV.G.1.e Musculoskeletal Management..........................IV.G.2.a Critical Elements for Musculoskeletal Management...............IV.G.2.a Critical Thinking Answer Key............... IV.G.2.h Copyright©2007 by Excelsior College. All rights reserved. xii Study Guide for the Clinical Performance in Nursing Examination Oxygen Management.......................................IV.G.3.a Evaluation Phase.................................................. IV.I.1 Critical Elements for 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 Critical Elements for Pain Management..................................IV.G.4.a Critical Thinking Answer Key................ IV.G.4.f Respiratory Management.................................IV.G.5.a Critical Elements for Respiratory Management.......................IV.G.5.a Critical Thinking Answer Key.................IV.G.5.j Wound Management........................................IV.G.6.a Critical Elements for 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 Critical Elements for 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 Critical Elements for Wound Management............................... IV.J.1.a Critical Thinking Answer Key................. IV.J.1.h Intravenous Medication..................................... IV.J.2.a Critical Elements for Intravenous Medications........................ IV.J.2.a Critical Thinking Answer Key................. IV.J.2.h IV Push Medication........................................... IV.J.3.a Critical Elements for Injectable IV Push Medications.............. IV.J.3.a Critical Thinking Answer Key................. IV.J.3.h 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 Critical Elements for 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Study Guide for the Clinical Performance in Nursing Examination 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 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. xiv Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 I Unit I: Introduction Section A: Overview Section B:Excelsior College Associate Degree Nursing Learning Resources 14th Edition, July 2007 Section C: Professional Learning Resources Section D: Excelsior College Resources Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.A.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.A.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.A.6 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.B.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Associate Degree Nursing Learning Resources 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.B.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 I.C.1 I.C.1 UNIT I Section C Professional Learning Resources 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.C.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Professional Learning Resources 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.C.4 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Professional Learning Resources 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.C.6 Study Guide for the Clinical Performance in Nursing Examination 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/ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Associate Degree Nursing Learning Resources 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.C.8 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Associate Degree Nursing Learning Resources 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.C.10 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 Email: [email protected] 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. I.D.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 II Unit II: Structure, Process, and Application Policies Section A: CPNE Structure Section B: CPNE Process Section C: Application Policies and Procedures 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.A.2 Study Guide for the Clinical Performance in Nursing Examination •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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.A.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.A.6 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.A.8 Study Guide for the Clinical Performance in Nursing Examination •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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.A.10 Study Guide for the Clinical Performance in Nursing Examination • 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.B.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.B.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Overriding Areas of Care Required Areas of Care Asepsis Caring Emotional Jeopardy Mobility Physical Jeopardy Fluid Management Vital Signs Copyright©2007 by Excelsior College. All rights reserved. II.B.6 Study Guide for the Clinical Performance in Nursing Examination Selected Areas of Care related to Assessment Management Abdominal Assessment Neurological Assessment Peripheral Vascular Assessment Respiratory Assessment Skin Assessment Comfort Management Musculoskeletal Management Oxygen Management Pain Management Respiratory Management Wound Management Other Selected Areas of Care Drainage and Specimen Collection 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.) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.B.8 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.B.10 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.B.12 Study Guide for the Clinical Performance in Nursing Examination • 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” This decision would be made if the subcommittee determined that • 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” This decision would be made if the subcommittee determined that • a scoring error was made AND • you successfully completed the requirements for passing the CPNE. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.C.2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.C.4 Study Guide for the Clinical Performance in Nursing Examination 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 14−20 calendar days prior to scheduled CPNE 4 $785.00 0−13 calendar days prior to scheduled CPNE 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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). 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.C.6 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. II.C.8 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 III Unit III: Preparing for the CPNE 14th Edition, July 2007 Section A: Learning Readiness Section B: Learning Strategies Section C: Managing Stress Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. III.A.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. III.A.4 Study Guide for the Clinical Performance in Nursing Examination “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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. III.B.2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. III.B.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. III.C.2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Example of Cause III.C.3 Copyright©2007 by Excelsior College. All rights reserved. III.C.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. III.C.6 Study Guide for the Clinical Performance in Nursing Examination • 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Dont’s Copyright©2007 by Excelsior College. All rights reserved. III.C.8 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.A.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.A.4 Study Guide for the Clinical Performance in Nursing Examination 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? Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.A.6 Study Guide for the Clinical Performance in Nursing Examination 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) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 The Planning Phase IV.A.7 Critical Thinking/Application to Practice 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.A.8 Study Guide for the Clinical Performance in Nursing Examination • 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 Critical Thinking/Application to Practice 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. _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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: 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.A.10 Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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. Critical Thinking/Application to Practice 8.Review the PCS Assignment Kardex for Cindy Burns, on the following page and complete the Planning Phase NCP that follows. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 √ √ 14th Edition, July 2007 ** faces scale Copyright©2007 by Excelsior College. All rights reserved. IV.A.12 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.A.14 Study Guide for the Clinical Performance in Nursing Examination 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) Critical Thinking/Application to Practice 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 √ √ ** Right leg CPM flexion 10-45 °; extension 0-10° 10 cycles/min while in bed √ ice bag continuously to right knee Copyright©2007 by Excelsior College. All rights reserved. IV.A.16 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 Spirometer x 5 repetitions ** 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.A.18 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 Spirometer x 10 repetitions ** √ wet to moist Normal Saline drsg, pack surgical incision cover with DSD ** Ampicillin 450 mg in 50 ml D5W Infuse over 30 minutes √ 14th Edition, July 2007 15 gtt/ml Copyright©2007 by Excelsior College. All rights reserved. IV.A.20 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 M M M D D D Copyright©2007 by Excelsior College. All rights reserved. IV.A.22 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 Note: only diagnostic label will be scored in the Planning Phase. Spirometer x 5 repetitions 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. 14th Edition, July 2007 * See sample NCPs Copyright©2007 by Excelsior College. All rights reserved. IV.A.24 Study Guide for the Clinical Performance in Nursing Examination 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 Instruct patient to use Incentive Note: only diagnostic label will be scored in the Planning Phase. Spirometer x 10 repetitions 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. Note: only diagnostic label will be scored in the Planning 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 Note: only diagnostic label will be scored in the Planning Phase. Fatigue [R/T sleep disturbance AEB complaints of feeling tired] Note: only diagnostic label will be scored in the Planning Phase. Copyright©2007 by Excelsior College. All rights reserved. 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 14th Edition, July 2007 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 Note: only diagnostic label will be scored in the Planning Phase. 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. Note: only diagnostic label will be scored in the Planning Phase. 20 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.A.26 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.B.2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.C.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.D UNIT IV Section D Overriding Areas of Care 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.D.1.a UNIT IV Section D.1 Asepsis Critical Elements for Asepsis The successful student 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.1.b Study Guide for the Clinical Performance in Nursing Examination 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). The successful student 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. 2. Protects self, others, and the environment from contamination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 3. Protects the patient from contamination 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.1.d Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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 Critical Thinking/Application to Practice 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Overriding Areas of Care –Asepsis Situation PPE Used IV.D.1.e Steps Taken to Protect Yourself 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 4. Disposes of contaminated material in the designated container(s) 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.1.f Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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 Before donning clean gloves and after removing soiled gloves at the end of the procedure. Taking an oral temperature Yes Before donning clean gloves and 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 Steps Taken to Protect Yourself 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Overriding Areas of Care –Asepsis Situation Entering the room of a patient on respiratory precautions Mask and hand washing Steps Taken to Protect Yourself 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 14th Edition, July 2007 PPE Used IV.D.1.g Copyright©2007 by Excelsior College. All rights reserved. IV.D.1.h Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.D.2.a UNIT IV Section D.2 Caring Critical Elements for Caring The successful student 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.D.2.b Study Guide for the Clinical Performance in Nursing Examination 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 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) 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 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.2.d Study Guide for the Clinical Performance in Nursing Examination 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, demeaning, abusive, or otherwise unacceptable 4. Uses physical expressions that are not overly familiar, patronizing, demeaning, abusive, or otherwise unacceptable 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 Critical Thinking/Application to Practice 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.D.2.f Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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?” 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.3.b Study Guide for the Clinical Performance in Nursing Examination •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. Critical Thinking/Application to Practice 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. What Area of Care or Critical Elements is the student violating? _________________________________________________________________________ _________________________________________________________________________ b. How should the student have approached the patient? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Overriding Areas of Care –Emotional Jeopardy IV.D.3.c Critical Thinking Answer Key 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. What Area of Care or Critical Elements is the student violating? This would be a failure under Emotional Jeopardy because the student has upset the patient to the point of being asked to leave. b. How should the student have approached the patient? 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. What Area of Care or Critical Elements is the student violating? 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.3.d Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.D.4.a UNIT IV Section D.4 Mobility Critical Elements for Mobility The successful student 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.D.4.b Study Guide for the Clinical Performance in Nursing Examination 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. Use of assistive devices 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Overriding Areas of Care –Mobility c. IV.D.4.c Presence of balance abnormalities 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.4.d Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Overriding Areas of Care –Mobility IV.D.4.e 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 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.” Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.4.f Study Guide for the Clinical Performance in Nursing Examination 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. _________________________________________________________________________ _________________________________________________________________________ Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Overriding Areas of Care –Mobility 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? 14th Edition, July 2007 Weakness, facial grimacing, verbalization of pain by the patient, verbalization of weakness by the patient and needing assistance to ambulate. Copyright©2007 by Excelsior College. All rights reserved. IV.D.4.h Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.D.5.b Study Guide for the Clinical Performance in Nursing Examination • 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Overriding Areas of Care –Physical Jeopardy IV.D.5.c Critical Thinking/Application to Practice For the following examples, rate the student’s behavior as pass or fail for the Area of Care Physical Jeopardy. Behavior 14th Edition, July 2007 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. Student Assignment: 89 y/o patient s/p 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 Copyright©2007 by Excelsior College. All rights reserved. IV.D.5.d Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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. 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. Student Assignment: 89 y/o patient s/p 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. Copyright©2007 by Excelsior College. All rights reserved. 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. 14th Edition, July 2007 IV.E UNIT IV Section E Required Areas of Care Fluid Management Vital Signs Required Areas of Care are tested in every Patient Care Situation for every student. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.E.1.a UNIT IV Section E.1 Critical Elements for Fluid Management The successful student 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 14th Edition, July 2007 OR OR Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.b Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. e) 14th Edition, July 2007 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 (1)Feeling the surrounding skin for changes 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: 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.d Study Guide for the Clinical Performance in Nursing Examination 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.) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Fluid Management 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.f Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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. 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 Copyright©2007 by Excelsior College. All rights reserved. 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 14th Edition, July 2007 Required Areas of Care –Fluid Management 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 Palpating the surrounding tissue for edema 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.h Study Guide for the Clinical Performance in Nursing Examination 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 (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 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Fluid Management IV.E.1.i Critical Thinking/Application to Practice 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.j Study Guide for the Clinical Performance in Nursing Examination 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: (1)Feeling the surrounding skin for changes 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 (regular or microdrops) of the calculated number of drops per minute Copyright©2007 by Excelsior College. All rights reserved. OR 14th Edition, July 2007 Required Areas of Care –Fluid Management IV.E.1.k (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 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.l Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Fluid Management 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.n Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Fluid Management IV.E.1.o 6. Records data related to 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.” Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.p Study Guide for the Clinical Performance in Nursing Examination 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Fluid Management IV.E.1.q 17. How would you measure urine output? _________________________________________________________________________ _________________________________________________________________________ 18. What are some of the possible outcomes for this patient? _________________________________________________________________________ _________________________________________________________________________ Critical Thinking Answer Key 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? 14th Edition, July 2007 Fluid overload. Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.r Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Fluid Management 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? 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.E.1.t Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.E.2.a UNIT IV Section E.2 Critical Elements for Vital Signs The successful student 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.2.b Study Guide for the Clinical Performance in Nursing Examination 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.) 1. Complies with established guidelines 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. Reading the instrument within a stated range of 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.2.d Study Guide for the Clinical Performance in Nursing Examination b. Counting within a stated range of 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) 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. Reading the instrument within a stated range of 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Vital Signs IV.E.2.e Critical Thinking/Application to Practice 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.E.2.f Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Required Areas of Care –Vital Signs 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% Critical Thinking Answer Key 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? 14th Edition, July 2007 According to the American Heart Association guidelines you pump the sphygmomanometer 20–30 mm higher than the highest baseline systolic. Copyright©2007 by Excelsior College. All rights reserved. IV.E.2.h Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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: Abdominal Assessment Neurological Assessment Peripheral Vascular Assessment Respiratory Assessment Skin Assessment 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.F.1.a UNIT IV Section F.1 Abdominal Assessment Critical Elements for Abdominal Assessment The successful student 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 7. Records data related to 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). The successful student 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.1.b Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Abdominal Assessment 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.” Critical Thinking/Application to Practice 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 unless contraindicated 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.1.d Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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). 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 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.” Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Abdominal Assessment IV.F.1.e Critical Thinking Answer Key Abdominal Assessment 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? 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.F.1.f Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.F.2.a UNIT IV Section F.2 Neurological Assessment Critical Elements for Neurological Assessment The successful student 1. Complies with established guidelines 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 14th Edition, July 2007 2) AND Dorsiflex or plantarflex both feet simultaneously OR Copyright©2007 by Excelsior College. All rights reserved. IV.F.2.b Study Guide for the Clinical Performance in Nursing Examination 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 7. Records data related to 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.) 1. Complies with established guidelines 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. Critical Thinking/Application to Practice 1.What type of patient would require monitoring of neurological status and might possibly be assigned for a PCS? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Neurological Assessment 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 c.Presenting visual, auditory, and tactile stimuli to a child between 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.2.d Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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 Copyright©2007 by Excelsior College. All rights reserved. AND 14th Edition, July 2007 Selected Areas of Care Related to Assessment Neurological Assessment 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. 7. Records data related to 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.2.f Study Guide for the Clinical Performance in Nursing Examination 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.” Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Neurological Assessment IV.F.2.g Critical Thinking Answer Key Neurological Assessment 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? 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.F.2.h Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.F.3.a UNIT IV Section F.3 Peripheral Vascular Assessment Critical Elements for Peripheral Vascular Assessment The successful student 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) 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.3.b Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Peripheral Vascular Assessment IV.F.3.c Critical Thinking/Application to Practice 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.3.d Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Peripheral Vascular Assessment f. IV.F.3.e 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. 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. Examples of acceptable recording: • “ 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.” 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.3.f Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Peripheral Vascular Assessment IV.F.3.g Critical Thinking Answer Key Peripheral Vascular Assessment 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. 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.F.3.h Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Peripheral Vascular Assessment 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? 14th Edition, July 2007 These are normal findings for an infant with coarctation of the aorta. With this condition decreased pedal pulses and slow capillary refill is expected. Copyright©2007 by Excelsior College. All rights reserved. IV.F.3.j Study Guide for the Clinical Performance in Nursing Examination 11. Sample Documentation 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. Copyright©2007 by Excelsior College. All rights reserved. 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 14th Edition, July 2007 IV.F.4.a UNIT IV Section F.4 Respiratory Assessment Critical Elements for Respiratory Assessment The successful student 1. Complies with established guidelines 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 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.) 1. Complies with established guidelines 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.4.b Study Guide for the Clinical Performance in Nursing Examination 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 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 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Respiratory Assessment IV.F.4.c 4. Records data related to a. Comparison of breath sounds bilaterally b. Abnormal breathing patterns 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. Examples of acceptable recording: • “ 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.” 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.4.d Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.F.5.a UNIT IV Section F.5 Skin Assessment Critical Elements for Skin Assessment 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 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) 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.5.b Study Guide for the Clinical Performance in Nursing Examination 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 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Assessment Respiratory Assessment IV.F.5.c 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, sheer and pressure effects, skin tears) c. temperature d. edema e. moisture (e.g., perspiration, incontinence, diarrhea, non intact ostomy/drainage system) 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.” 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.F.5.d Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 Musculoskeletal Management Oxygen Management Pain Management Respiratory Management Wound Management Remember: Assess-Implement-Reassess for all management Areas of Care 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.G.1.a UNIT IV Section G.1 Comfort Management Critical Elements for Comfort Management The successful student 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.1.b Study Guide for the Clinical Performance in Nursing Examination 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. 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 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.1.d Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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.” Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Comfort Management IV.G.1.e Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Critical Thinking Answer Key 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.1.f Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.G.2.a UNIT IV Section G.2 Musculoskeletal Management Critical Elements for Musculoskeletal Management The successful student 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.G.2.b Study Guide for the Clinical Performance in Nursing Examination 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 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. Critical Thinking/Application to Practice 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 Musculoskeletal Management S/P knee replacement (TKR) Diabetes Post CVA with unilateral paralysis Post fall fractured femur Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Musculoskeletal Management IV.G.2.c 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 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 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 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.2.d Study Guide for the Clinical Performance in Nursing Examination 4. Applies supportive or therapeutic devices to the designated body part(s) 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 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 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Musculoskeletal Management IV.G.2.e Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.G.2.f Study Guide for the Clinical Performance in Nursing Examination 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 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Musculoskeletal Management 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. Patient response(s) to measures implemented 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.” 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.2.h Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key Musculoskeletal Management 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 Musculoskeletal Management • 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Musculoskeletal 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.G.2.j Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.G.3.a UNIT IV Section G.3 Oxygen Management Critical Elements for Oxygen Management The successful student 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.G.3.b Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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. ______________________________________________________________________________ ______________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management 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) 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.3.d Study Guide for the Clinical Performance in Nursing Examination 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 Critical Thinking/Application to Practice 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. Patient response to measures implemented 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management 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. Examples of acceptable recording: “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.” Critical Thinking/Application to Practice 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. Sample Documentation 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.3.f Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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? Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management 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) Sample Documentation 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.G.3.h Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.G.4.a UNIT IV Section G.4 Pain Management Critical Elements for Pain Management The successful student 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 visual analog 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 b.Asking a child to rate level of pain using a 0-5 faces scale or age-appropriate visual analog scale 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 level of pain by a.Asking an adult patient to rate level of pain using a 0–10 scale or visual analog scale b.Asking a child to rate level of pain using a 0–5 faces scale or age-appropriate visual analog scale 14th Edition, July 2007 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) Copyright©2007 by Excelsior College. All rights reserved. IV.G.4.b Study Guide for the Clinical Performance in Nursing Examination 6. Records a. Patient’s level of pain b. Pain relief measures implemented c. Patient response to measures implemented 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 or visual analog scale b.Asking a child to rate level of pain using a 0-5 faces scale or age-appropriate visual analog 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) 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management 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. Critical Thinking/Application to Practice 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. 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 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.4.d Study Guide for the Clinical Performance in Nursing Examination 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 visual analog 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 b.Asking a child to rate level of pain using a 0–5 faces scale or age-appropriate visual analog scale OR d.Observing behaviors indicative of pain in a patient unable to rate his or her pain (e.g., moaning, grimacing, clutching, restlessness) 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Pain Management IV.G.4.e 6. Records: a. Patient’s level of pain b. Pain relief measures implemented c. Patient response to measures implemented 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. Critical Thinking/Application to Practice 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.4.f Study Guide for the Clinical Performance in Nursing Examination 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 Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management 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. Repositioned on left side. Back rub given. 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 14th Edition, July 2007 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. Repositioned on left side. Back rub given. 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. Copyright©2007 by Excelsior College. All rights reserved. IV.G.4.h Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 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. 14th Edition, July 2007 IV.G.5.a UNIT IV Section G.5 Respiratory Management Critical Elements for Respiratory Management The successful student 1. Complies with established guidelines 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 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 14th Edition, July 2007 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 by the patient’s condition Copyright©2007 by Excelsior College. All rights reserved. IV.G.5.b Study Guide for the Clinical Performance in Nursing Examination 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 unless contraindicated 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) 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 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.) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Respiratory Management IV.G.5.c 1. Complies with established guidelines 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 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 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.5.d Study Guide for the Clinical Performance in Nursing Examination c. Observing breathing patterns 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Respiratory Management 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 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 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.5.f Study Guide for the Clinical Performance in Nursing Examination 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 2)Repeats respiratory exercise as ordered or as indicated by the patient’s condition 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Respiratory Management d. IV.G.5.g 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 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) Repeats as necessary to remove secretions 14th Edition, July 2007 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) Repeats as necessary to remove secretions Copyright©2007 by Excelsior College. All rights reserved. IV.G.5.h Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Respiratory Management 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. Abnormal breathing patterns 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.” 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.5.j Study Guide for the Clinical Performance in Nursing Examination “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.” Critical Thinking/Application to Practice 6.What should be added or changed to make the two unacceptable notes acceptable according to the Critical Elements within this Area of Care? _________________________________________________________________________ _________________________________________________________________________ Critical Thinking/Application to Practice 7.List assessment findings that would support the nursing diagnosis of Ineffective Airway Clearance. _________________________________________________________________________ _________________________________________________________________________ Critical Thinking Answer Key Respiratory Management 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Respiratory Management IV.G.5.k 3. 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.G.5.l Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Respiratory Management 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 14th Edition, July 2007 1. Ineffective or absent cough 2. Inability to move airway secretions 3. Abnormal breath sound 4. Abnormal respiratory rhythm, rate and depth Copyright©2007 by Excelsior College. All rights reserved. IV.G.5.n Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.G.6.a UNIT IV Section G.6 Wound Management Critical Elements for Wound Management The successful student 1. Complies with established guidelines 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: 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. IV.G.6.b Study Guide for the Clinical Performance in Nursing Examination 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. Patient response to measures implemented Wound Management is the assessment of a wound and the implementation of measures to clean, irrigate, and protect the wound and surrounding skin. 1. Complies with established guidelines 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Wound Management IV.G.6.c Critical Thinking/Application to Practice 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.G.6.d Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Selected Areas of Care Related to Management Wound Management b.Measures implemented to cleanse, irrigate, and protect the wound and surrounding skin c. IV.G.6.e Patient response to measures implemented 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.” Critical Thinking Answer Key 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? 14th Edition, July 2007 Increasing size of ulcer, increasing pain, foul smelling drainage, redness around ulcer. Copyright©2007 by Excelsior College. All rights reserved. IV.G.6.f Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.H UNIT IV III Section H A Other Selected Areas of Care Drainage and Specimen Collection Enteral Feeding Irrigation Medications Patient Teaching 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.H.1.a UNIT IV Section H.1 Drainage and Specimen Collection Critical Elements for Drainage and Specimen Collection The successful student 1. Complies with established guidelines 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.1.b Study Guide for the Clinical Performance in Nursing Examination 1. Complies with established guidelines 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care Drainage and Specimen Collection IV.H.1.c Critical Thinking/Application to Practice 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.1.d Study Guide for the Clinical Performance in Nursing Examination Examples of acceptable recording: “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.” Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 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. 14th Edition, July 2007 IV.H.2.a UNIT IV Section H.2 Enteral Feeding Critical Elements for Enteral Feeding The successful student 1. Complies with established guidelines 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 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 the location of a nasogastric tube by using one of the following methods before initiating gastric feeding, unless contraindicated by: 1) Aspirating gastric contents 14th Edition, July 2007 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: Copyright©2007 by Excelsior College. All rights reserved. IV.H.2.b Study Guide for the Clinical Performance in Nursing Examination 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. 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 OR b)Documenting the flow rate setting on the enteral feeding pump on the PCS Recording Form Regulates the flow rate when required by either 2) 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 number required to deliver the prescribed volume b.Verifies the location of the nasogastric tube at least once during the PCS by one of the following methods, unless contraindicated: 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) When measurement of gastric residual is designated: c. 1) Measures gastric residual 2) Reinstills gastric residual unless contraindicated 3) Determines the amount of feeding to be administered 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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. 1. Complies with established guidelines 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.2.d Study Guide for the Clinical Performance in Nursing Examination 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) Critical Thinking/Application to Practice 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 Copyright©2007 by Excelsior College. All rights reserved. + Amount of Water = Strength of Solution ml ml ½ strength ml ml 3/4 strength ml ml Full strength 14th Edition, July 2007 Other Selected Areas of Care 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 otherwise designated Critical Thinking/Application to Practice 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. Determines the amount of feeding to be administered 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) 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) 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.2.f Study Guide for the Clinical Performance in Nursing Examination 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. 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: 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 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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. 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 OR b)Documenting the flow rate setting on the enteral feeding pump on the PCS Recording Form Regulates the flow rate when required by either 2) 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 number required to deliver the prescribed volume b.Verifies the location of the nasogastric tube at least once during the PCS by one of the following methods, unless contraindicated: 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) When measurement of gastric residual is designated: c. 1) Measures gastric residual 2) Reinstills gastric residual unless contraindicated 3) Determines the amount of feeding to be administered 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.2.h Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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. Critical Thinking/Application to Practice 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._________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care Enteral Feeding IV.H.2.i Critical Thinking Answer Key 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? 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.H.2.j Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 2) Administer enteral feeding as prescribed 14th Edition, July 2007 IV.H.3.a UNIT IV Section H.3 Irrigation Critical Elements for Irrigation The successful student 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) 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.3.b Study Guide for the Clinical Performance in Nursing Examination 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.” Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care Irrigation IV.H.3.c Critical Thinking/Application to Practice 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. Sample Documentation 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.3.d Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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. Sample Documentation 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 brown fluid and stool returned. 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 brown fluid and stool returned. 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.H.4.a UNIT IV Section H.4 Medications Critical Elements for Medications The successful student 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. 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 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) Feeling the surrounding skin for changes in temperature 14th Edition, July 2007 OR 2) Clears air from the tubing before initiating flow c. Palpating the surrounding tissue for edema Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.b Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care Medications IV.H.4.c 1. Complies with established guidelines related to medication 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 administration record (MAR) 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.d Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 3. Measures the prescribed dosage 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.f Study Guide for the Clinical Performance in Nursing Examination 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. Medical record number 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. Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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. Critical Thinking/Application to Practice 11.While you are drawing up the medication, you realize you are using the wrong needle size. What should you do? _________________________________________________________________________ _________________________________________________________________________ 6. Uses the prescribed route and/or site for administering medications 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. 7. Administers the prescribed medication to the designated patient 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.h Study Guide for the Clinical Performance in Nursing Examination Critical Thinking/Application to Practice 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). Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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.) Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.j Study Guide for the Clinical Performance in Nursing Examination 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. Critical Thinking/Application to Practice 17. Calculate the following: Erythromycin 500 mg in 100 ml normal saline IV 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 by using one of the following methods: 1) Feeling the surrounding skin for changes in temperature 2) OR Palpating the surrounding tissue for edema 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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. When an intermittent venous access device is used: 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.l Study Guide for the Clinical Performance in Nursing Examination 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 Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.n Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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: 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? 100 × 15 divided by 30 = 50 drops/min 17. Calculate the following: Erythromycin 500 mg in 100 ml normal saline IV To run over 30 minutes via infusion control device. 14th Edition, July 2007 What is the rate you should set on the infusion control device? 100 × 60 divided by 30 = 200 ml Copyright©2007 by Excelsior College. All rights reserved. IV.H.4.p Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.H.5.a UNIT IV Section H.5 Patient Teaching Critical Elements for Patient Teaching The successful student 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.5.b Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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. Critical Thinking/Application to Practice 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.5.d Study Guide for the Clinical Performance in Nursing Examination 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, Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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?” Critical Thinking/Application to Practice 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 14th Edition, July 2007 a. Assessment of learning readiness b. Information provided c. Patient response to information provided Copyright©2007 by Excelsior College. All rights reserved. IV.H.5.f Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Other Selected Areas of Care 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 Musculoskeletal Management • U se of devices-walkers, canes, crutches, wheelchairs, elastic stockings (TEDs) • Cast care, splint care • Proper body mechanics • The hazards of immobility 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.H.5.h Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.I.1 UNIT IV Section I Evaluation Phase Critical Elements for the Evaluation Phase The successful student 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.2 Study Guide for the Clinical Performance in Nursing Examination 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. 2.Selects one priority nursing diagnosis a.Writes a related factor for the selected nursing diagnosis 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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) 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. Respiratory Management 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.6 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. Critical Thinking/Application to Practice 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.8 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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? Critical Thinking/Application to Practice 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. IV.I.10 Study Guide for the Clinical Performance in Nursing Examination 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 Spirometer x 10 repetitions ** √ √ ** 0830 L ovenox 30 mg Subq 0830 Multivitamin ÷ tab PO √ √ Copyright©2007 by Excelsior College. All rights reserved. ** right leg CPM; flexion 10-45 °; extension 0-10°; 10 cycles/ min while in bed √ ice bag continuously to right knee 14th Edition, July 2007 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 Instruct patient to use Incentive Note: only diagnostic label will be scored in the Planning Phase. Impaired physical mobility [R/T tissue trauma AEB need for assistance getting OOB] IV.I.11 Spirometer x 10 repetitions Assess strength of lower extremities express feelings of increased strength Assist patient with use of walker when getting OOB. Note: only diagnostic label will be scored in the Planning Phase. 12 gtt/min 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.12 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.14 Study Guide for the Clinical Performance in Nursing Examination 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. Abdominal Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Comfort Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Drainage and Specimen Collection _ __________________________________________________________________________________ _ __________________________________________________________________________________ Irrigation _ __________________________________________________________________________________ _ __________________________________________________________________________________ Musculoskeletal Management 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.” _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Evaluation Phase IV.I.15 Neurological Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Oxygen Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Pain Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Patient Teaching _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Peripheral Vascular Assessment 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.” _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.16 Study Guide for the Clinical Performance in Nursing Examination Respiratory Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Respiratory Management 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 _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Evaluation Phase IV.I.17 Other Observations taken as offered and tolerated by patient. _Fluids __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.18 Study Guide for the Clinical Performance in Nursing Examination 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 Spirometer x 5 repetitions ** 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Evaluation Phase IV.I.19 PCS #2 Will O’Brien 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 Note: only diagnostic label will be scored in the Planning Phase. 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.] Note: only diagnostic label will be scored in the Planning Phase. 14th Edition, July 2007 Elicit the patient’s preferences in the organization of care Copyright©2007 by Excelsior College. All rights reserved. IV.I.20 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Evaluation Phase IV.I.21 PCS #2 Will O’Brien 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. —— 14th Edition, July 2007 95% 95% 1 1 Copyright©2007 by Excelsior College. All rights reserved. IV.I.22 Study Guide for the Clinical Performance in Nursing Examination 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. Abdominal Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Comfort Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Drainage and Specimen Collection _ __________________________________________________________________________________ _ __________________________________________________________________________________ Irrigation _ __________________________________________________________________________________ _ __________________________________________________________________________________ Musculoskeletal Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Evaluation Phase IV.I.23 Neurological Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 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 Peripheral Vascular Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.24 Study Guide for the Clinical Performance in Nursing Examination Respiratory Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Respiratory Management 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 Pressure Ulcer Risk Assessment Score ___________ ___________ Risk ___________ No Risk _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Wound Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Evaluation Phase IV.I.25 Other Observations _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.26 Study Guide for the Clinical Performance in Nursing Examination 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 Spirometer x 10 repetitions ** √ wet to moist NormalSaline drsg, pack surgical incision cover with DSD ** Ampicillin 450 mg in 50 ml D5W Infuse over 30 minutes √ 15 gtt/ml Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 Note: only diagnostic label will be scored in the Planning 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. Note: only diagnostic label will be scored in the Planning Phase. 20 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.28 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.30 Study Guide for the Clinical Performance in Nursing Examination 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. Abdominal Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 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. _ __________________________________________________________________________________ _ __________________________________________________________________________________ Drainage and Specimen Collection _ __________________________________________________________________________________ _ __________________________________________________________________________________ Irrigation _ __________________________________________________________________________________ _ __________________________________________________________________________________ Musculoskeletal Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Evaluation Phase IV.I.31 Neurological Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Oxygen Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Pain Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Patient Teaching _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Peripheral Vascular Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.32 Study Guide for the Clinical Performance in Nursing Examination Respiratory Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Respiratory Management 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 Pressure Ulcer Risk Assessment Score ___________ ___________ 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. _ __________________________________________________________________________________ _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.34 Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. PCS #2 Will O’Brien 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.I.36 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.J UNIT IV Section J Simulation Laboratory Stations 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.J.1.a UNIT IV Section J.1 Wound Management Critical Elements for Wound Management The successful student 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.1.b Study Guide for the Clinical Performance in Nursing Examination 1. Complies with established guidelines related to managing a wound The sterile inner wrapper of the supplies is a sufficient sterile field. 2. Removes the dressing without contaminating the wound It is acceptable to wear clean gloves when removing the soiled dressing. 3. Disposes of the dressing in the designated container For the laboratory portion of the examination, a waste paper basket will serve as the designated container for disposal of the dressing. 4. Prepares gauze for application to wound bed 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. 7. Secures the dressing 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations Wound Protection IV.J.1.c Correct Incorrect 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.1.d Study Guide for the Clinical Performance in Nursing Examination Incorrect Incorrect Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.1.f Study Guide for the Clinical Performance in Nursing Examination Excelsior College Treatment Record Treatment Record Date Time Initial 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 1800 Apply a wet to moist saline gauze dressing to the mannequin’s wound 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: ______________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations Wound Protection IV.J.1.g Critical Thinking/Application to Practice 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? _________________________________________________________________________ _________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.1.h Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.J.2.a UNIT IV Section J.2 Intravenous Medication Critical Elements for Intravenous Medications The successful student 1. Complies with the established guidelines related to medication administration. 2. Selects the prescribed medication using the medication administration record. 3. 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. Medical record number 4. Uses the prescribed route and/or site for administering the medication 5. Administers the prescribed medication to the designated patient 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 complications immediately before administering the medication by using one of the following methods: 1)Feeling the surrounding skin for changes in temperature OR 2)Palpating the surrounding tissue for edema 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 administration record (MAR) 8. Maintains asepsis 9. Completes all Critical Elements within 20 minutes 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.2.b Study Guide for the Clinical Performance in Nursing Examination 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 medication administration. 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 administration record. Select the prescribed medication using the medication administration record (MAR) provided. The physician’s order will be clearly written on the MAR. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations Intravenous Medication 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 Infuse over 20 minutes 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 “Patient’s Name” GI Bleed Patient Name: ______________________________ Diagnosis: ____________________________ 75438 12/15/58 Date of Birth: _______________________________ Med Record Number#: ________________ No Known Allergies Allergies: ___________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.2.d Study Guide for the Clinical Performance in Nursing Examination 3. 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. Medical record number 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. 4. Uses the prescribed route and/or site for administering the medication 5. Administers the prescribed medication to the designated patient 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations Intravenous 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.2.f Study Guide for the Clinical Performance in Nursing Examination 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 the surrounding skin for changes in temperature OR 2)Palpating the surrounding tissue for edema 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. d.Regulates the flow to deliver the prescribed amount in the 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 administration record. Initial the MAR in the appropriate box designating that you administered the medication. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations Intravenous 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. 9. Completes all Critical Elements within 20 minutes 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. Critical Thinking/Application to Practice 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. Drop factor = 10 gtts/ml. 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. 14th Edition, July 2007 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? Copyright©2007 by Excelsior College. All rights reserved. IV.J.2.h Study Guide for the Clinical Performance in Nursing Examination Critical Thinking Answer Key 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. Drop factor = 15 gtts/ml. 25 gtts/min. 3. Erythromycin 500 mg in 100 ml normal saline to infuse over 20 minutes. Drop factor = 10 gtts/ml. 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.J.3.a UNIT IV Section J.3 IV Push Medication Critical Elements for Injectable IV Push Medications The successful student 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 Form before administering the medication. 4. Measures the prescribed dosage 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. Medical record number 6. Uses the prescribed route and/or site for administering the medication 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. When an intermittent venous access device is used: 14th Edition, July 2007 OR 1) Palpating the surrounding tissue for edema Aspirates for blood return unless contraindicated Copyright©2007 by Excelsior College. All rights reserved. IV.J.3.b Study Guide for the Clinical Performance in Nursing Examination 2)Flushes with the prescribed solution prior to medication administration 3)Flushes with designated solution after medication administration 9. Records medication administered on medication administration record (MAR) 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 medication administration 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. 2. Selects the prescribed medication using the Medication Administration Record (MAR) 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 Copyright©2007 by Excelsior College. All rights reserved. Zofran Synthroid Dexamethasone Toradol 14th Edition, July 2007 Simulation Laboratory Stations IV Push Medication IV.J.3.c Read the MAR completely before you start to prepare your medications. Excelsior College Medication Administration Record (MAR) Dates Administered Medication-DosageFrequency Route of ADM 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 “Patient’s Name” CHF Patient Name: ______________________________ Diagnosis: ____________________________ 643210 12 - 15 - 36 Date of Birth: _______________________________ Med Record Number#: ________________ No Known Allergies Allergies: ___________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.3.d Study Guide for the Clinical Performance in Nursing Examination 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. Clinical Performance in Nursing Examination (CPNE) Nursing Simulation Laboratory Recording Form Name: _ __________________________________________________________ Social Security Number: __________________________________________ Station C: Injectable Medications: IV Push IVP Medication __________ ml __________ minutes Use Space Below for Calculations Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations IV Push Medication IV.J.3.e 4. Measures the prescribed dosage 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. 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 b. Medical record number 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. Be very deliberate in this action because the CE may not be able to observe you visually scanning the ID band. 6. Uses the prescribed route and/or site for administering medications 7. Administers the prescribed medication to the designated patient 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. 8. When IV medication is to be administered by push: 14th Edition, July 2007 a.Records the volume of medication and time to be administered on the Simulation Laboratory Recording Form before administering the medication. Copyright©2007 by Excelsior College. All rights reserved. IV.J.3.f Study Guide for the Clinical Performance in Nursing Examination b.Assesses insertion site for dislocation, infiltration, or other complications immediately before administering medication by using one of the following methods: 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. Injects the medication at the designated rate 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations 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. When an intermittent venous access device is used: 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 medication administration 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.3.h Study Guide for the Clinical Performance in Nursing Examination 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. 11.Completes all the Critical Elements in 15 minutes 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? Critical Thinking Answer Key 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 IV.J.4.a UNIT IV Section J.4 Injectable Medication: Intramuscular or Subcutaneous Critical Elements for Injectable Medications: Intramuscular or Subcutaneous The successful student 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 4. Measures the prescribed dosage 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. Medical record number 6. Uses the correct needles size for injections 7. Uses the prescribed route and/or site for administering the medication 8. Administers the prescribed medication to the designated patient 9.Records medication administered on medication administration record (MAR) 10. Maintains asepsis 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.4.b Study Guide for the Clinical Performance in Nursing Examination 1. Complies with established guidelines related to medication administration 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. 2. Selects the prescribed medication using the Medication Administration Record (MAR) 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) Copyright©2007 by Excelsior College. All rights reserved. IM Compazine Toradol Benadryl Nubain 14th Edition, July 2007 Simulation Laboratory Stations Injectable Medication: Intramuscular or Subcutaneous IV.J.4.c Excelsior College Medication Administration Record (MAR) Dates Administered Medication-DosageFrequency Route of ADM 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’s Name” Patient Name: ______________________________ Diagnosis: ____________________________ 5/05/45 643210 Date of Birth: _______________________________ Med Record Number#: ________________ No Known Allergies Allergies: ___________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.4.d Study Guide for the Clinical Performance in Nursing Examination 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. Clinical Performance in Nursing Examination (CPNE) Nursing Simulation Laboratory Recording Form Name: _ __________________________________________________________ Social Security Number: __________________________________________ 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 Use Space Below for Calculations Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations Injectable Medication: Intramuscular or Subcutaneous IV.J.4.e 4. Measures the prescribed dosage 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. 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. Medical record number 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. 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 8. Administers the prescribed medication to the designated patient 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. IV.J.4.f Study Guide for the Clinical Performance in Nursing Examination 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. 11.Completes all the Critical Elements in 15 minutes Prepare, administer, and record the medication administered in 15 minutes. Critical Thinking/Application to Practice 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 medication administration. 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Simulation Laboratory Stations Injectable Medication: Intramuscular or Subcutaneous IV.J.4.g Critical Thinking Answer Key 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. 14th Edition, July 2007 Invert the vial, keep the needle below the fluid level, withdraw the fluid slowly and tighten the needle on the syringe. Copyright©2007 by Excelsior College. All rights reserved. IV.J.4.h Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.A.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.A.4 Study Guide for the Clinical Performance in Nursing Examination Nursing Theory Examinations Refers to the content of the nursing curriculum that is measured by computer testing rather than performance testing. Overriding Areas of Care 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix A CPNE Definitions App.A.5 Required Areas of Care 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.A.6 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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] 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.B.2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.C.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.D.2 Study Guide for the Clinical Performance in Nursing Examination 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.) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. App.D.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix D CPNE Student Orientation 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. 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. App.D.6 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix D CPNE Student Orientation 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 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. App.D.8 Study Guide for the Clinical Performance in Nursing Examination 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.) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 App.E.1 Appendix UNIT III Section E A Universal Time Chart (24-hour Clock) 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. App.E.2 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.F.2 Study Guide for the Clinical Performance in Nursing Examination •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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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) You will have 20 minutes to complete this station. 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. You will have 15 minutes to complete this station. 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) 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.F.4 Study Guide for the Clinical Performance in Nursing Examination • 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 ____________. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 App.G.1 Appendix G CPNE Simulation Laboratory Report Clinical Performance in Nursing Examination (CPNE) Simulation Laboratory Report 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: 14th Edition, July 2007 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. Copyright©2007 by Excelsior College. All rights reserved. App.G.2 Study Guide for the Clinical Performance in Nursing Examination 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. The successful student 1. Protects self, others, and the environment from contamination 2. Protects the patient from contamination 3. Disposes of contaminated material in the designated container(s) 4. Establishes a sterile field where required Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix G Simulation Laboratory Report 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. The successful student 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 surface _______ 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 Critical Elements within 15 minutes _______ “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:_ ___________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.G.4 Study Guide for the Clinical Performance in Nursing Examination 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. The successful student 1.Complies with the established guidelines related to medication administration _______ 2.Selects the prescribed medication using the medication administration record (MAR) _______ 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 Medical record number _______ 4.Uses the prescribed route and/or site for administering the medication _______ 5. Administers the prescribed medication to the designated patient _______ 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 _______ 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 the surrounding skin for changes in temperature or 2) palpating the surrounding tissue for edema _______ c. Clears air from tubing before initiating flow d.Regulates the flow to deliver the prescribed amount in the designated period of time (± 5 drops per minute) _______ _______ 7.Records the medication administered on the medication administration record (MAR) _______ 8. Maintains asepsis _______ 9. Completes all Critical Elements within 20 minutes _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix G Simulation Laboratory Report App.G.5 “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:_ ___________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.G.6 Study Guide for the Clinical Performance in Nursing Examination 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). The successful student 1.Complies with the 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 _______ 4. Measures the prescribed dosage _______ 5.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 Medical record number _______ 6.Uses the prescribed route and/or site for administering the medication _______ 7. Administers the prescribed medication to the designated patient _______ 8. When IV medication is to be administered by push: a.Records the volume and time of medication 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 1) Feeling around the skin for changes in temperature. OR 2) Palpating the surrounding tissue for edema _______ Injects the medication at the designated rate _______ c. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix G Simulation Laboratory Report d. App.G.7 When an intermittent venous access device is used: 1) Aspirates for blood return unless contraindicated _______ 2)Flushes with prescribed solution prior to medication administration _______ 3)Flushes with prescribed solution after medication administration _______ 9.Records the medication administered on the medication administration record (MAR) _______ 10. Maintains asepsis _______ 11. Completes all Critical Elements within 15 minutes _______ “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:_ ___________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.G.8 Study Guide for the Clinical Performance in Nursing Examination 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. The successful student 1.Complies with the 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. _______ 4. Measures the prescribed dosage _______ 5.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 Medical record number _______ 6. Uses the correct needle size for injections _______ 7.Uses the prescribed route and/or site for administering the medication _______ 8. Administers the prescribed medication to the designated patient _______ 9.Records the medication administered on the medication administration record (MAR) _______ 10. Maintains asepsis _______ 11. Completes all Critical Elements within 15 minutes _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix G Simulation Laboratory Report App.G.9 “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:_ ___________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.G.10 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.H.2 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix H Student PCS Response Form 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 Clinical Performance in Nursing Examination Student PCS Response Form 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) 14th Edition, July 2007 Fail No Penalty (Write name of hospital test site) ___________ NPAC: _____________________________________ ___________ SPAC: _____________________________________ ___________ MPAC: _____________________________________ Copyright©2007 by Excelsior College. All rights reserved. App.H.4 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix H Student PCS Response Form 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.H.6 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 14th Edition, July 2007 Appendix H Student PCS Response Form App.H.7 Copyright©2007 by Excelsior College. All rights reserved. App.H.8 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 14th Edition, July 2007 Appendix H Student PCS Response Form App.H.9 Copyright©2007 by Excelsior College. All rights reserved. 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 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix H Student PCS Response Form App.H.11 OR OR OR OR OR OR OR 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.H.12 Study Guide for the Clinical Performance in Nursing Examination 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. Abdominal Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Comfort Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Drainage and Specimen Collection _ __________________________________________________________________________________ _ __________________________________________________________________________________ Irrigation _ __________________________________________________________________________________ _ __________________________________________________________________________________ Musculoskeletal Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix H Student PCS Response Form App.H.13 Neurological Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Oxygen Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Pain Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Patient Teaching _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Peripheral Vascular Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.H.14 Study Guide for the Clinical Performance in Nursing Examination Respiratory Assessment _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Respiratory Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Skin Assessment ___________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Wound Management _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix H Student PCS Response Form App.H.15 Other Observations _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ _ __________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.H.16 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.I.2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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? 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.J.2 Study Guide for the Clinical Performance in Nursing Examination 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 achievement of the outcome 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix I Self Assessment for the CPNE Clinical Competencies 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 e.Documents assessment, intervention and evaluation 11. Performing assessments a. Neurological b. Respiratory c. Abdominal 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.J.4 Study Guide for the Clinical Performance in Nursing Examination Clinical Competencies 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 d.Documents assessment, intervention 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix J Self Assessment for the CPNE Clinical Competencies 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 e.Documents assessment, intervention 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 d.Documents assessment, intervention 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.J.6 Study Guide for the Clinical Performance in Nursing Examination Clinical Competencies 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 d.Documents assessment, intervention 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 e.Documents assessment, intervention 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 App.K.1 Appendix K Patient Care Situation (PCS) Scoring Tool 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.K.2 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool Clinical Performance in Nursing Examination Patient Care Situation (PCS) Scoring Tool 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.K.4 Study Guide for the Clinical Performance in Nursing Examination 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):_________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.K.6 Study Guide for the Clinical Performance in Nursing Examination ____ 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. The successful student 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: ________ Overriding Areas of Care ____ 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. The successful student 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 _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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. The successful student 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.K.8 Study Guide for the Clinical Performance in Nursing Examination ____ 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. The successful student 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool App.K.9 Required Areas of Care ____ 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. The successful student 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 14th Edition, July 2007 _______ _______ _______ _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.10 Study Guide for the Clinical Performance in Nursing Examination 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 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 (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 _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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.) The successful student 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: 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) _______ 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 Copyright©2007 by Excelsior College. All rights reserved. App.K.12 Study Guide for the Clinical Performance in Nursing Examination 1)Asking an adult to rate level of pain using a 0–10 scale or visual analog scale _______ or 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 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. The successful student 1.Complies with 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 _______ 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 _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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.) The successful student 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. The successful student 1.Complies with established guidelines _______ 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 _______ 14th Edition, July 2007 e.Removes tube when assigned _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.14 Study Guide for the Clinical Performance in Nursing Examination 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.) The successful student 1.Complies with established guidelines _______ 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 (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 with ± 30 minutes of scheduled time _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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 number required to deliver the prescribed volume 1)Aspirating gastric contents _______ or 2)Instilling 10–20 ml of air into stomach while auscultating (5 ml for children under 2 years of age) 14th Edition, July 2007 _______ b.Verifies the location of the nasogastric tube at least once during 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. _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.16 Study Guide for the Clinical Performance in Nursing Examination ____ IRRIGATION: The introduction of fluid into and drainage from any body orifice or cavity. The successful student 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.) The successful student 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.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 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 the surrounding skin for changes in temperature _______ _______ or 2)Palpating the surrounding tissue for edema _______ _______ c.Clears air from tubing before initiating flow Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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). The successful student 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 leas 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 14th Edition, July 2007 a. Verifying the prescribed traction weight _______ b. Assuring that ropes are unobstructed _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.18 Study Guide for the Clinical Performance in Nursing Examination 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.) The successful student 1.Complies with established guidelines _______ 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 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 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 Copyright©2007 by Excelsior College. All rights reserved. _______ _______ 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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.) The successful student 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 14th Edition, July 2007 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 _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.20 Study Guide for the Clinical Performance in Nursing Examination ____ 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.) The successful student 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 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 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 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 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 _______ c.Patient response to measures implemented _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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. The successful student 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. The successful student 1.Complies with established guidelines _______ 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 2)Noting movement of the extremity(ies) in a child under 3 or a noncommunicating adult _______ _______ 3.Records data related to bilateral comparison of extremities: 14th Edition, July 2007 a.Presence or absence of the most distal pulses _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.22 Study Guide for the Clinical Performance in Nursing Examination 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.) The successful student 1.Complies with established guidelines _______ 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.) The successful student 1.Complies with established guidelines _______ 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) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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 _______ 2)Repeats respiratory exercise as ordered or as indicated by the patient’s condition _______ 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 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 14th Edition, July 2007 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 _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.24 Study Guide for the Clinical Performance in Nursing Examination ____ 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, 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. The successful student 1.Complies with established guidelines _______ 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 _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix K Patient Care Situation (PCS) Scoring Tool 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 14th Edition, July 2007 b.Measures implemented to cleanse, irrigate, and protect the wound and surrounding skin _______ c.Patient response to measures implemented _______ Copyright©2007 by Excelsior College. All rights reserved. App.K.26 Study Guide for the Clinical Performance in Nursing Examination ____ 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. The successful student 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 _______ 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. 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 achievement of the outcome _______ 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 _______ Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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.” 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.L.2 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.M.2 Study Guide for the Clinical Performance in Nursing Examination 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) Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix M Reasonable Accommodations for Students with Disabilities App.M.3 C. Accommodation(s) to Nursing Performance Examinations 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. App.M.4 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. App.N.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.O.2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 14th Edition, July 2007 Appendix O Additional Practice Care Plans App.O.3 Copyright©2007 by Excelsior College. All rights reserved. App.O.4 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix O Additional Practice Care Plans 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 Note: only diagnostic label will be scored in the Planning Phase. Risk for impaired skin integrity (r/t bedrest) Reposition patient in bed maintain intact skin Assess skin Note: only diagnostic label will be scored in the Planning 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.O.6 Study Guide for the Clinical Performance in Nursing Examination 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. ** √ Copyright©2007 by Excelsior College. All rights reserved. Osmolyte HN @ 65 ml/hr continuously via kangaroo pump 14th Edition, July 2007 14th Edition, July 2007 Appendix O Additional Practice Care Plans App.O.7 Copyright©2007 by Excelsior College. All rights reserved. App.O.8 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix O Additional Practice Care Plans App.O.9 #2 Answer Key Risk for deficient fluid volume Monitor IV fluid intake. demonstrate no skin tenting Assess hydration status. Note: only diagnostic label will be scored in the Planning Phase. Impaired Physical Mobility ambulate patient with assistance ambulate to doorway Assess patient’s response to Note: only diagnostic label will be scored in the Planning 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.O.10 Study Guide for the Clinical Performance in Nursing Examination 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 ** ** ** √ Copyright©2007 by Excelsior College. All rights reserved. A&D ointment to rash in diaper area — c each diaper change 14th Edition, July 2007 14th Edition, July 2007 Appendix O Additional Practice Care Plans App.O.11 Copyright©2007 by Excelsior College. All rights reserved. App.O.12 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Appendix O Additional Practice Care Plans App.O.13 #3 Answer Key Allow for breast feeding episodes Comfort, impaired have fewer episodes of crying ad lib Hold infant. Note: only diagnostic label will be scored in the Planning Phase. Impaired skin integrity demonstrate decrease in rectal and buttock area redness Check diaper for urine and loose stools Apply A & D ointment Note: only diagnostic label will be scored in the Planning 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.O.14 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.P.2 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 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. 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. App.P.4 Study Guide for the Clinical Performance in Nursing Examination 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. Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007 Study Guide for the Clinical Performance in Nursing Examination 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 14th Edition, July 2007 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 Copyright©2007 by Excelsior College. All rights reserved. 2 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 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 14th Edition, July 2007 Study Guide for the Clinical Performance in Nursing Examination 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. 4 Study Guide for the Clinical Performance in Nursing Examination 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 Copyright©2007 by Excelsior College. All rights reserved. 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 14th Edition, July 2007 Study Guide for the Clinical Performance in Nursing Examination 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 14th Edition, July 2007 Copyright©2007 by Excelsior College. All rights reserved. 6 Study Guide for the Clinical Performance in Nursing Examination Copyright©2007 by Excelsior College. All rights reserved. 14th Edition, July 2007
