Nur 299: Cpne (Step By Step)

Front 1

Wound Station 10 edition***

Back 1

wet-to-dry dressing
supplies, tear tape, write write write;
glove, remove dressing, inspect, biohazard;
sterile field (last first), pour off saline, six inches above;
sterile gloves up up up;
pack, dress, tape, little tape.

Front 2

IV Push

Back 2

IV Push Lab Station (on which you will no longer aspirate---Read MAR, get med, check MAR, write med, write time, write dose;
Wipe bottle, overdraw med, air out, on MAR.
Wipe port (on IV bag), overdraw, air out, by arm (repeat for second flush);
Glove, unclamp line, palpate;
De-glove, ID MAR; re-glove, verbalize;
Clean, attach, inject, sharps.
Clean, attach, watch, note time, push, sharps;
Clean, attach, inject, sharps;
DEGLOVE, sign MAR, done, clean table.

Front 3

IM/SQ

Back 3

Read MAR, get med, check MAR, write med, write time, write dose;
Wipe bottle, overdraw med, air out, on MAR.
Wipe port (on IV bag), overdraw, air out, by arm (repeat for second flush);
Glove, unclamp line, palpate;
De-glove, ID MAR; re-glove, verbalize;
Clean, attach, inject, sharps.
Clean, attach, watch, note time, push, sharps;
Clean, attach, inject, sharps;
DEGLOVE, sign MAR, done, clean table.

Front 4

IV Push--11th edition

Back 4

Read MAR, get med, check MAR, write med, write time, write dose;
Wipe bottle, overdraw med, air out, on MAR.
Wipe port (on IV bag), overdraw, air out, by arm (repeat for second flush);
Glove, unclamp line, palpate;
De-glove, ID MAR; re-glove, verbalize;
Clean, attach, inject, sharps.
Clean, attach, watch, note time, push, sharps;
Clean, attach, inject, sharps;
DEGLOVE, sign MAR, done, clean table.

Front 5

IV minibag

Back 5

amount of med in ml’s X tubing drop factor (gtts/ml)
--------------------------
amount of time in minutes
MAR, math;
Glove, assess site, tubing;
Deglove, lower primary;
Backflow, kink, remove spike;
insert spike, hang, ID to MAR, regulate;
Sign MAR.

Front 6

Skin Assessment

Back 6

“A-CITEM-B”, which is exactly the steps listed above (Assess skin--color, integrity, temp, edema, moisture--Braden scale). 1)Assess skin for color, integrity, temperature, edema, amd moisture (CITEM). You must assess the heels and sacrum as a minimum and how much further you will go depends on what exactly is assigned and the condition of the patient. Edema only needs to be noted (documented) as present or absent. You do not need to rate it.

2) Braden scale, if assigned. A copy of this is in the study guide and will be provided for you at the exam, should you need it. You need to score the patient on it and designate the patient as either “no risk for pressure ulcer formation” or “risk for pressure ulcer formation”. Remember to document thee score the patient got on the Braden scale. You need to be within 3 points of what the CE gets. They are no longer doing Braden-Q on the peds patients, so you will only have to scale adults

Front 7

Medication Area

Back 7

“WOW GIPSIS”, 1) Wash your hands. The med area is a clean area and you will fail if you don’t wash prior to touching anything there.

2) Obtain meds. The CE will show you how to get the appropriate meds--some hospital keep all meds locked up while others have drawers for the patients that are practically out in the open.

3) Wash hands again in room. No kidding. You need to wash your hands everytime you walk into the patient’s room. Some hospitals, like Albany Medical Center, have the alcohol rub right outside the door and you are allowed to use that in lieu of actually washing again. Even though it is right outside the door, it counts as washing when you walk into the patient’s room, so don’t sweat that one. In Racine, the alcohol rub is inside the patient’s room, which makes things much more simple.

4) Glove. Glove. Glove. Obviously, you don’t need to glove if you are giving pills, but run it through your mind anyway, just in case. The gloves at Albany were near the door rather than by the bedside (a ridiculous set-up, in my opinion), so you actually have to think of it when you first walk into the room. That shouldn’t be too hard, since you need gloves to assess the IV site.

5) Precheck--this is what you need to do before you give certain med (such as taking an apical pulse prior to giving digoxin). There aren’t too many meds you will have to do a precheck on, but make sure you think of this as a step so you don’t forget when it needs to be done.

6) ID to MAR. You must ID the patient against the MAR, checking name & DOB or medical record (two of the above must be checked) and you must do this immediately before giving the med.

7) Site Clean. Assuming you are giving an injection, clean the site with alcohol swab.

8) Inject/give med. Don’t forget to count any water they drink in the process of taking pills on your I&O.

9) Sign MAR. You must sign the MAR within 30 minutes of giving the med. Personally, I would think you would have to be insane not to sign it immediately upon giving themed, seeing as how you have the MAR right there, but regardless, leaving it for more than 30 minutes will automatically fail you.

Front 8

Fluid Management

Back 8

1) Checking patient’s hydration status (skin turgor, fontanelle, OR mucus membranes). For infants, you MUST check the fontanelle. For most others, you are going to want to check the mucus membranes by having them stick out their tongue. Remember that on elderly patients, skin turgor is not a good indication of hydration status.

2) Note Fluid restrictions, amount and type. Some patient’s will be NPO, some restricted to a particular amount per day, others on a clear liquid diet, and others with no restrictions at all. This will be marked on your kardex.

3) Verify drip rates or ICD settings. This must be done within twenty minutes of starting the implementation phase. Remember that you must have written the proper gravity drip rate on your care plan form prior to turning it in. If you don’t, you will fail the planning phase. You do NOT have to write the ICD number on the care plan, but you will certainly want to make a note of it on your grid so you have it handy. At this time, you must also confirm that the right solution is hanging and the expiration date on the bag is good.

4) Assess the IV site. Again, must be done within twenty minutes of starting implementation. In addition to palpating the site (WITH GLOVES ON!), be sure to ask the patient how the site feels.

5) Document I&O throughout PCS. When you first walk into the patient’s room, take charge of this requirement by making sure whatever cups or pitchers they have are filled. You can actually ask the patient not to drink anything until you have done this (explain you have to document it), but don’t delay it or the CE will nail you on it. Do not forget that any meal trays that are in the room when you enter count on YOUR I&O--don’t let anyone take the tray out of the room until you have had a chance to count up what was on thee tray and what the patient took in.

6) Change IV bag if necessary--that is, if the main IV bag runs out, you will likely need to replace it (depending on the physician’s orders). This is treated exactly like giving a med--you will need to ID the patient to the MAR and check the IV site and tubing before administering. As of October 1, 2004, you must check the pt’s ID directly before actualy turning on the IV.

7) Check for air in IV tubing. This should really be done at the same time as checking the patient’s IV site.

8) Flush intermittent venous access device (IVAD) if prescribed. Again, this is treated exactly as a med and, as of October 1, 2004, you do NOT aspirate for blood return on a flush or a med into an IVAD.

9) D/C an IV, if prescribed. This is fairly straight-forward and simple. Remember to wear gloves.

Front 9

Vitals

Back 9

1) Temperature: If you are taking an oral temp, make sure the patient hasn’t eaten or had a drink within the previous 15 minutes. If you need to do an axillary temp, make sure you are placing the probe right in the center of the axilla.

2) Pulse: can substitute an apical pulse for a radial pulse, but not the other way around. , if you can find one.
3) Respirations: count for a full minute and patient’s shoulder, chest, or (in the case of children) belly.
4) Blood Pressure: pump more than 30 mmHg above baseline. stethoscope).
5) Weight: always, always put a barrier between the patient and the scale; balance (zero out) the scale prior to weighing.
6) O2 Sats: this is very simple. baseline O2 Sat
7) Pain Level: ask the patient what their pain is on the 0-10 scale (or faces, for peds).

Front 10

Fluid Management

Back 10

HIDS
1) hydration status (skin turgor, fontanelle, OR mucus membranes). For infants, MUST check the fontanelle. check the mucus membranes by having them stick out their tongue. Remember elderly patients, skin turgor is not a good indication of hydration status.

2) intake/output--Note Fluid restrictions, amount and type--NPO, some restricted to a particular amount per day, clear liquid diet, no restrictions.

3) Drip Rate--Verify drip rates or ICD settings. This must be done within twenty minutes of starting the implementation phase. Remember that you must have written the proper gravity drip rate on your care plan form prior to turning it in. At this time, confirm that the right solution is hanging and the expiration date on the bag is good.
4) Assess the IV site. Again, must be done within twenty minutes of starting implementation. In addition to palpating the site (WITH GLOVES ON!), be sure to ask the patient how the site feels.

5) Document I&O throughout PCS. When you first walk into the patient’s room, take charge of this requirement by making sure whatever cups or pitchers they have are filled. You can actually ask the patient not to drink anything until you have done this (explain you have to document it), Do not forget that any meal trays that are in the room when you enter count on YOUR I&O--don’t let anyone take the tray out of the room until you have had a chance to count up what was on thee tray and what the patient took in.

6) Change IV bag if necessary--that is, if the main IV bag runs out. This is treated exactly like giving a med--you will need to ID the patient to the MAR and check the IV site and tubing before administering.
7) Check for air in IV tubing. This should really be done at the same time as checking the patient’s IV site.

8) Flush intermittent venous access device (IVAD) if prescribed. Again, this is treated exactly as a med and you do NOT aspirate for blood return on a flush or a med into an IVAD.
9) D/C an IV, if prescribed. Remember to wear gloves.

Front 11

Fluid Management Notes--what to count

Back 11

Flushes used for NG or G-tube count as intake.

Count an IV bag only if it finishes completely infusing during your PCS.
You do not count partial IV bags unless the bag is discontinued during your PCS and even then, if you are not the one to stop the bag flowing (i.e., the staff nruse does it), clarify with your CE whether you or the staff nurse is going to count it.

If patient’s breakfast (or lunch) tray is in the room, but empty, when you arrive, you must still count it on I&O--even if they completely finished it before you ever saw them. Basically, whoever takes the tray out needs to count the tray’s content on I&O.
G-tube residual only counts on I&O if you detach the syringe. So, if you check residual and get 25 ml back and immediately reinstill it without detaching the syringe, you do NOT have to count it as I&O. If, for whatever reason, you do detach the syringe, it must be counted on output. When you reinstill it (which you will almost always do to maintain electrolyte balance), you count it on intake.

Diapers must be weighed for I&O. Weight the wet diaper, then a dry one--the difference is the output, in mls. 1 gram=1 ml.

Any drainage whatsoever (JP tube, other wound drainage, chest tube drainage, etc) must be counted as output IF (and only if) you empty the associated drainage container. If you do not empty it, do not count it. If you are unsure whether you should be emptying something, ask the CE. Generally, if it isn’t marked on your kardex as assigned, you aren’t responsible for emptying it.

Front 12

Comfort Management

Back 12

“AODRR” (ask, observe, do 3, reassess, record).

1) Ask the patient how comfortable they are (or uncomfortable, as the case may be). It’s a good idea to use the 0-10 scale so that you have a concrete reference point when reassessing and documenting.

2) Observe/watch the patient for signs of discomfort--grimacing, guarding, etc.--note these in your documentation.

3) Perform three comfort measures--from changing a baby’s diaper to fluffing the patient’s pillows. You can use lotion on them, straighten their linens, help them wash their face and hands, give them a backrub, offer to turn on the TV, read them, whatever. You don’t actually have to find three measures they want--offering three different comfort measures fulfills the critical elements.
4) Reassess their comfort level after having done the comfort measures--particularly if one of those measures happened to be a PRN pain med given by your or the staff RN. Use the same 0-10 scale so you have a concrete reference point to document. With any luck, it will be a little lower than it was when you first asked them.

Front 13

Mobility

Back 13

BEAMR
B= Balance. How well balanced is the patient when they walk or move?

E=Extraneous movements. Are they displaying any out of the ordinary movements, such as twitches or obvious muscle spasms? Do they move all limbs appropriately?

A= Alignment/Assistive devices. How is their general body alignment? When you come into the room, are they slouched down in the bed or are they in comfortable, good alignment? Do they require any assistive devices (crutches, walkers, body pillows of any sort, etc) to ambulate or maintain appropriate alignment?

M= Move to alignment. It is required in this area of care that you move the patient into good alignment in bed if they are not already so. When moving a patient, make sure you get the CEs help, if needed, and completely avoid shearing or dragging. Have them tuck their chin to chest and fold their arms over their chest if you need to move them up in the bed.

R=Response of patient. If you had to move the patient or use an assistive device with them or doing anything else regarding this area of care, how did the patient respond? Did they tolerate it without complaint? Did they stay in proper body alignment, or complain of discomfort?

Front 14

Musculoskeletal Management

Back 14

“J MASHT”.
Joints bilat
Muscle strength bilat
Active/Passive ROM
Support/therap devices
Heat/cold
Traction

1) Joint flexibility bilateral assessment. Basically, how well can the patient move their joints--specifically, the joints of the area to which you are assigned (upper or lower extremities).

2) Muscle strength bilateral assessment. Again, this will be either upper or lower extremities. For upper, have the patient push and pull against your hands with theirs. They can grasp your fingers and do this while you exert a little opposite pressure you can feel if their strength is normal or weak.

3) Active or Passive range of motion. Either upper or lower extremities, whichever is assigned. Joint flexibility will show here, obviously. Make sure you support the joints while doing passive range of motion. For active range of motion, actually do all the movements with them on your own body so they can see exactly what is expected. You might feel ridiculous making the motions you want the patient to do, but this ain’t the time for mis-communications. You must do adduction/abduction and flexion/extension.

4) Supportive or therapeutic devices. You need to use these, if assigned or appropriate. These can be continuous passive motion devices, pillows of any kind to support alignment (including regular pillows used to support injured limbs), or whatever. This information should be on your kardex, but make sure you scan the patient’s chart for it, just in case.

5) Heat or Cold application. Neither of these should be left on more than 20 minutes or they will start to have the reverse effect. Actually write down not only the time you apply it, but also the time it needs to be taken off. If the time it needs to be taken off is after you finish your PCS, report it to the staff nurse. Also make sure you have a barrier between the patient skin and the heat/cold. You can use a towel, a washcloth, a disposable blue check, whatever. More than likely, if they are getting heat or cold applications, there is already something in their room specifically to protect the skin. Ask the staff nurse during report.

6) Traction. Check alignment of the patient, alignment of the traction (make sure all weights hang freely), and the total weight Adjust anything that needs adjusting, including the patient.

Front 15

Before you walk into the room

Back 15

1. make sure you have your grid done with every pertinent item on it--two sets of recent vitals-- Know what their pain scale has been, particularly within the past day or so; level the oxygen should be set at. 2. Write down all the supplies you think you might need and collect them all prior to going in.
3. Take the extra time to do a little creative visualization regarding what you will do immediately upon going into the room:introduce yourself, wash your hands, ID the patient and check their cup of water/pitcher (for I&O).
3. Know your 20 minute checks.
4. If pt is asleep--Don't be shy about doing everything you can get away with without actually waking the patient up. If the patient is still asleep after you've peeked at the ID bracelet, checked their oxygen level, checked their IV drip rates, and done everything else you can, lightly touch them on their shoulder and speak quietly.