CPNE Mnemonics

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CPNE Mnemonics
2010-08-07 22:17:02
CPNE critical elements

Mnemonics for critical elements
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  1. Oxygen Management
    • SOAP
    • Skin Assessement: check skin around canula, face mask. Is intact? Red?
    • Oxygen check: 02 sats, or cap refill
    • Activity: assess pts' response to activity. Tired? SOB?
    • Position: position to help facilitate breathing
  2. Pain

    • Pain: assess pain using appropriate scale
    • Reminder: reposition, relaxation (do something for pt's pain)
    • Need to reassess: once more, remember to document pain level before intervention (intervention, response, pain after)
  3. Patient Teaching
    RID of ignorance

    • Ready to learn: is pt ready/willing to learn. "Mr. Smith, is this a good time to talk about ______?"
    • Identify learning needs: note what pt teaching is assigned with. "Mr. Smith, what do you know about ______?"
    • Did pt understand: Provide evidence such as pt statement that indicates pt understood. "Mr. Smith, can we tell you what we just talked about?"
  4. Abdominal Assessment
    4P'S - Look, Listen, Feel

    • Privacy: Be sure to shut door and pull curtain
    • Pee: ask pt is they have to pee.
    • Pain: ask pt if they are experiencing any adb pain.
    • Position: if there are no inhibiting factors (pain, limited ROM, resp concerns) place pt in as supine a position as poss and elevate knees.
    • Suction: turn suction off, and remember to turn on at end
    • Look: note any distention, discoloration
    • Listen: auscultate 4 quadrants for bowel sounds. Listen for a full minute before declaring bowel sounds absent.
    • Feel: palpate 4 quadrants, assessing for pain, tenderness, rigidity.
  5. Neuro Assessment

    • LOC: person, place, time. (document)
    • Assess Fontanel: pt less than 1 yr. Must sit child up to perform assessment. Document flat, depressed, or bulging.
    • Movement: ask pt to elevate arms while gripping index and middle fingers with hands. Lower ext- do plantarflex or dorsiflex.
    • PERRL: (CE will have penlight) Dim lights and place one hand along nose vertically to shield. Assess equality, roundness, reactivity. Document bilateral comparison.
  6. Peripheral Vascular Assessment
    Please Make Sure To Check Cap Refill

    • Pulses: check most distal pulses for assigned extremity.
    • Movement: assess movement of most distal portion of assigned extrem. Ask to wiggle toes, fingers, stumps, etc.
    • Sensation: ask pt to close eyes. Lightly touch most distal portion of assigned extremity. Ask pt to tell you which digits you are touching.
    • Temperature: assess temp of distal portion of assigned extremity and document as warm, hot, cold.
    • Color or Cap Refill: only one is required.
  7. Respiratory Assessment

    • Oxygen Saturation: if assigned.
    • Position: assist pt into a position to facilitate assessment. (sitting or on side)
    • Assess RRAP: rhythm, rate, accessory muscle use, pattern. Breath sounds (document as clear or abnormal). Watch rise and fall of chest for assym movement. Listen to top lobes first, then bottom.
    • Instruct pt to breathe as deeply as possible while assessing.
    • Record data...make sure it is structured as bilateral comparison.
  8. Respiratory Management

    • Oxygen Saturation: if assigned.
    • Position: assist pt into a position to facilitate assessment. (sitting or on side)
    • Assess rhythm, accessory muscle use, pattern (RAP), breath sounds (document as clear orabnormal). Watch rise and fall of chest for assymetrical movement. Listen to top then bottom.
    • Instruct pt to breathe as deeply as possible while assessing.
    • Record data...make sure it is structured as bilateral comparison.
    • How did pt tolerate deep breathing and cough
    • Always perform deep breathing and coughing exercise.
    • Incentive spirometer, if assigned.
    • Reassess/record -status of resp conditions prior to and after interventions compared. Must be documented, as well as pt's response to interventions.
  9. Skin Assessment
    TIME to check Color of Skin

    • Temperature: assess temp of pt's skin
    • Integrity: assess integrity of pt's skin. (lesions, rashes, sheer, pressure effects, skin tears) 2 areas (occiput, trochantar, heels, sacrum)
    • Moisture: abnormal moisture (perspiration, incontinence, diarrhea, non-intact ostomy/drainage system)
    • Edema: documented only as present or absent
    • Color: assess color of skin. If normal document as "skin color appropriate for ethnicity."
  10. Medication
    MARS & 5 rights

    • MAR: confirm 5 rights (pt, med, dose, route, time)
    • Allergies: Also apical pulse - if required
    • Recheck MAR to pt ID band immediately before administering meds
    • Sign the MAR: name, initial, ECSN
  11. Musculoskeletal Management

    • Mobility status: ssess mobility of designated extremities.
    • Abnormalities: note any abnormalities, atrophy, etc that are related to designated extremities.
    • Pain: ask pt is they are experiencing any pain or increased pain with movement of designated extremities.
    • Hot or Cold pack, if assigned
    • Apply/adjust devices
    • Traction
    • ROM exercises
  12. Mobility

    • Mobility status
    • Abnormalities
    • Devices: does pt use knee brace, walker, cane?
    • Ambulate
    • Turn
    • Offload
    • Position

    (Must do one of last 4..ambulate, turn, offload, position)
  13. Fluid Management
    Have I Drank Something?

    • Hydration status
    • I and O's
    • Drip rate
    • Site check
  14. Enteral Feeding

    • Record:
    • Amout of formula AND
    • Type of formula
    • Fowlers: position in Fowlers to receive tube feeding
    • Examine gastric tube/abd
    • Verify placement: verify G tube by aspirating gastric contents OR instilling 20 cc air bolus and listening.
    • Expiration date of formula
    • Record rate in 20 Minute drill: a pt that has running tube feeding IS part of 20 min drill
  15. Safety
    • SCABS
    • Side rails up x 3
    • Call Light/phone
    • Ask if can do anything
    • Bed in locked/low position
    • Skid proof socks
  16. Comfort Management
    COMFORT ERS (Attempt 3)

    • Comfort: do 3
    • Observe for discomfort
    • Meds PRN
    • Face wash
    • Oral care
    • Relaxation
    • Treat with heat/cold
    • Evaluate comfort at end
    • Reposition
    • Simple back rub