Documentation cpne

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Appendix G

Blank Student PCS Response Form385

2014Excelsior College. All rights reserved. | November 2014 | 21st Edition

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CPNEPCSASSIGNMENTKARDEX|PCS#________________

Name

M/F

Room#

DOB

Hospital#

Forinformationonly

Exam

start

time

Implementationstarttime

Scheduledendtime

Timeadded

Actualendtime

Admittingdiagnosis

Admissiondate

Surgerydate

Surgicalprocedure

Patientsnurse

SAFETY(Acompo

nentofphysicaljeopardy)

Siderails

Upper

Lower

Restraints

Other

SpecialNeeds

Allergies

Vision

Hearing

Other

FLUIDMANAGEMENT

Intake

Output

Weighdiapers

Parenteral

Solution

FlowRate

Gravity

ow

Dropfactor

Infusioncontroldevice

NextSolution

DiscontinueperipheralIV

Cannulacoverwith

Enteral

Nothingbymouth

Fluids

AdLib

Encourage

Restrict

Diet

VITALSIGNS

Temperature

Radialpulse

Apicalpulse

Respirations

Bloodpressure

Manual

Automatic

Weight

Oxygensaturation

LevelofPain

FLACCpainscale

05FACESpainscale

010Verbalpainscale

Observedbehaviors

MOBILITY

Bedrest

Bathroo

mp

rivileges

Reposit

ion

Other

Outofbedtochair

Transfer

Other

Ambulatory

status

Indepen

dent

Assistance

Other


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21st Edition | November 2014 | 2014Excelsior College. All rights reserved.

SELECTEDAREASOFCARE

Abdominalass

essment

Neurologicalassessment

Peripheralneu

rovascularassessment

Upperextremities

Lowerextremities

RespiratoryAs

sessment

Oxyg

ensaturation

Skinassessme

nt

Medications

SeeMAR

Intravenousmedication

SeeMAR

Grav

ity

ow

Dropfactor

Infusioncontroldevice

Type

Intermittentvenousaccessdevice

Assignedushsolution

Patientteachin

g

________________

Co-assignedwith

Irrigation/instillation

Solu

tion

Main

tenanceofintermittentvenousaccessdevice

Assignedushsolution

Comfortm

anagement

Comfortinterventions

Administermedications(seeMedications)

Applicationofheat

Applicationofcold

Mouthcareequipment

Musculosk

eletalmanagement

Assignedextremity(ies)

Activerangeofmotion

Passiverangeofmotion

Supportivedevices

Applicationof

Heat

Cold

Traction

Oxygenmanagement

Oxygenrate

Cannula

Mask

Croupette

Oxygensaturation

Painmana

gement

Painscaleorassessmenttooltouse

Painreliefinterventions

Administermedications(seeMedications)

Applicationofheat

Applicationofcold

Respiratorymanagement

Deepbreathing

Coughing

Mechanicaldevices

Chestpercussion

Suction

Woundmanagement

Irrigationsolution

Woundprotection

Steriledressing

Cleandressing

TopicalPreparation

Drainageandspecimencollection

Entera

lfeeding

Dietorder

BottleFeed

Tubefeeding/ush

Checkresidual


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Appendix G



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Clinic

alPerformanceinNursingExaminatio

n(CPNE)

Plann

ingPhasePlanofNursingCare

NURSINGDIAGNOSIS

MEASUR

ABLEEXPECTEDPATIENTOUTCOME

NURSINGINTERVENTIONS

1.

Thepatie

ntwill:

1.

Then

ursewill:

Patientassessmenttobep

erformedvalidatingthenursingdiagnosis:

2.

Then

ursewill:

NURSINGDIAGNOSIS

MEASUR

ABLEEXPECTEDPATIENTOUTCOME


2.

Thepatie

ntwill:

1.

Then

ursewill:

Patientassessmenttobep

erformedvalidatingthenursingdiagnosis:

2.

Then

ursewill:


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ClinicalPerformanceinNursingExamination(CPNE)

REV

ISEDPlann

ingPhase

PlanofNursingCare

NURS

INGDIAGNOSIS

MEASURABLEEXPECTEDPATIENTOUTCOME


1.

Thepatien

twill:

1.

Thenursewill:

Patientassessmenttobepe

rformedvalidatingthenursingdiagnosis:

2.

Thenursewill:

Reasonforchangingplan:

NURS

INGDIAGNOSIS

MEASURABLEEXPECTEDPATIENTOUTCOME


2.

Thepatien

twill:

1.

Thenursewill:

Patientassessmenttobepe

rformedvalidatingthenursingdiagnosis:

2.

Thenursewill:

Reasonforchangingplan:

Completeonlytheboxesthatyouarerevising

and/orchangingfromt

heoriginalPlanningPhasePlanof

NursingCarealongwiththereasonfortherevision/change(s)

onthisRevisedPlanningPhasePlanofNursingCareform.


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Clinica

lPerformanceinNursingExamination

(CPNE)

Evalua

tion

PhasePlanof

NursingCare

Writeyou

rinitialsonthelinebelowifthePlanningPhasePlanof

NursingC

aredidNOTneedtoberevised.

______________________

(initials)

NURSINGDIAGN

OSIS

MEASURABLEEXPECT

ED

PATIENTOUTCOME

NURSINGINTERVENTION#1

NURSINGINTERVENTION#2

Thepatientwill:

Thenursewill:

Thenursewill:

RelatedFactor(etiologyorriskfactor)

Patientsprogresstowardachievem

entoftheoutcome:

Met

PartiallyMet

Unmet

Writethepatientsresponsesthatsu

pportthepatientprogresstowardstheoutcome.

SignsandSymptoms

Rationaleexplainingwhythis

nursingdiagnosisisapriorityforthisspecicpatientduringthisPCS:


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DATE

MEDICATION ADMINISTRATION RECORD (MAR)

Medication / Dosage / Route / Time Initial when given

Signature Initials

Patient name

Date of Birth Med Record #

Allergies


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Appendix G



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PCS Recording Form

The student will record:

1. All information required by the specic critical elements as listed under the shaded areas of care.

2. Nursing care performed for all assigned required and selected areas of care.

3. Any observation of the patients condition that could inuence subsequent care.

Recording Directions:

Describe all assessment ndings and nursing care performed by the areas below that apply.

Medications should be recorded on the medication administration record (MAR).

Fluid Management

Enteral intake (amount) Parenteral intake (type and amount) Output (type and amount)

Hydration status (choose one)

Skin turgor

OR

Mucous membrane

OR

Fontanel

Parenteral uids

Current solution

ICD setting

OR

Calculated drops/minute

Condition of IV site

Temperature

OR

Edema

New Solution

Condition of IV site when IV discontinued

Intermittent venous accessdevice maintenance

Condition of IV site

Temperature

OR

Edema

Flush (type and amount)

Intravenous Medications

ICD setting

OR

Calculated drops/minute

IV site

Temperature

OR

Edema

Flush (type and amount)

Mobility

Vital Signs

First Set Second Set

Temperature

Pulse Rate

Respirations

Blood pressure

Weight

Oxygen

saturation

Level of pain

Enteral Feeding

Kind of feeding

Rate of feeding

Pump setting

Amount of feeding

Gastric residual amount


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Narrative Nurses Notes

Document the pertinent patient data including all related assessment ndings for

Assigned Areas of Care not included on the previous page of the Student PCS Response Form.

Write your assessment results from the original Planning Phase Plan of Nursing Care, and if using the

Revised Planning Phase Plan of Nursing Care, onlyif the assessment is not documented as part of another

assigned area of care.

Assessment Results for Nursing Diagnosis #1

Assessment Results for Nursing Diagnosis #2

Assessment Results for Revised Nursing Diagnosis/Diagnoses

ABDOMINAL ASSESSMENT

COMFORT MANAGEMENT

DRAINAGE AND SPECIMEN COLLECTION


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IRRIGATION/INSTILLATION

MUSCULOSKELETAL MANAGEMENT

NEUROLOGICAL ASSESSMENT

OXYGEN MANAGEMENT


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PAIN MANAGEMENT

PATIENT TEACHING

PERIPHERAL NEUROVASCULAR ASSESSMENT

RESPIRATORY ASSESSMENT


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Appendix G



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RESPIRATORY MANAGEMENT

SKIN ASSESSMENT

WOUND MANAGEMENT


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