- If the order says for patient to perform I/S x5 and I put that on my care plan, but when I get into the room the patient can only do 2, do I have to revise my care plan?
The interventions are to be carried out in the room. If you attempted to carry out the intervention and the patient partially did them, did it move the patient toward the outcome? If the answer is yes even though they only did two, then you would not have to revise your care plan. You would tell the examiner during the implementation phase that you want to revise and why.
- What if the CE assigns respiratory management with deep breathing and coughing and I/S x 5 but CE tells you that the patient’s lung sounds are clear?
If you observe in the chart or receive report that breath sounds are clear, it does not matter if you are assigned respiratory management or not, they don’t have a problem. If they don’t have a problem, you don’t address it in the planning phase. Now, once you get into the room, if you feel like airway clearance is still an important focus even though there are no current problems, you can revise to a risk for care plan but you would be changing your entire care plan because you would not have entered the room with Ineffective airway clearance as your Nanda.
- What are reasons to revise your care plans?
When you realize the problem no longer exists, you would need to revise it. You have the option to just revise the Nanda to a “risk for” or you can change the care plan completely depending on which is the stronger argument. All interventions must be carried out with your patient. If an intervention has been refused or the order has changed and that intervention is no longer needed then you would also have to revise. It is okay for the outcome not to be met so that does not need a revision. The only time the outcome is considered for revision is if you want to change the focus. For example, if you used “patient will have palpable, strong, and equal pedal pulses bilaterally” and they already do but they have cold feet, then you would revise your outcome to the patient will have warm feet bilaterally.
- If we choose to revise the care plan, do we ask the CE to step out of the room to discuss, or discuss in front of the patient. If so, what is a professional way to do so as to not put the patient in emotional jeopardy?
If you wish to change some part of the care plan, just say to the patient I will be stepping out of your room for a few minutes. You can then say to the CE that you are revising the care plan and what you are changing and why.
- If you focus on breath sounds as an outcome for Ineffective breathing pattern, is that okay?
The outcome idea should also come from your Mosby’s or care plan book. If the examiner says ‘show me where you got this outcome’ and you cannot, it is their discretion to pass or fail you on the decision you made to use that outcome. Having clear breath sounds is not an outcome option in Mosby’s for Ineffective breathing pattern.
- Would saying breath sounds will be “clearer” during pcs be acceptable?
The outcome has to be clear and measurable. How do you measure “clearer?” The breath sounds are either clear or abnormal. The outcome would be, “The patient will have clear breath sounds in upper and lower lobes bilaterally during the pcs.”
- Is it appropriate to say “patient will have normal bowel sounds” for an outcome?
Bowel sounds are either present or absent for documentation during this exam however, for the outcome it is best when written as follows, “The patient will have active bowel sounds in all four quadrants during the pcs.”
- Is saying “patient will demonstrate increased tolerance” for an Activity intolerance outcome okay?
For Activity intolerance, you need to focus on the activity and the intolerance in the outcome so how will they demonstrate an increased tolerance? What do you expect to see? Be specific. An example would be, “The patient will ambulate with no shortness of breath during the pcs.” Ambulation is the activity and shortness of breath is the intolerance that you don’t want to see.
- If you write an outcome for Impaired tissue integrity saying “the patient will have no breakdown during pcs,” is that okay?
With Impaired tissue integrity, the outcome usually focuses on drainage so you would say “the patient will have no drainage to the _____(region) during the pcs.” If you say they will have no breakdown, that is not appropriate during the timeframe you are with the patient and you really want to try to make it something potentially achievable during the pcs.
- What if I don’t put “during pcs” on the outcome?
The outcome must tell who is going to do it, what they are going to do, and over what time frame. The time frame should be during the pcs which is appropriate because that is the time you are with the patient or you can say after interventions. If you say at the end of the pcs, then you would have to go back and check at the end of the pcs so you don’t want to hang yourself with that.
- If the patient has perfusion issues in one leg, do I focus on that one leg in the outcome?
When you are performing the peripheral neurovascular assessment, you always compare bilaterally therefore in your outcome, you always address bilaterally as well as narrate “when compared bilaterally.” An example: the patient will have palpable, strong, and equal pedal pulses bilaterally during pcs.
- Are we able to bring the nursing diagnosis book into the PCS so if we need to revise, we can ensure the aeb/interventions are being approved/verified? Seems odd to bring it into the patient’s room, not having a place to set it without being awkward but not sure how else to do this?
You are allowed to bring the nursing diagnosis book with you. The CE may tell you where you can keep the book at the nurse’s station but you will not be taking it into the patient’s room with you. It is your job to let the CE know what you are thinking of changing the care plan to but you will formally look it up and make changes on the form once you step out of the room after you have completed everything with the patient. Make sure you do not write in your book except for your name.
- Please clarify, when documenting bowel sounds, do we only document present or absent or do we note hypo/hyper? CE states present or absent but in some of the samples given it is written hypoactive.
Present or absent are accepted and have less problems trying to figure them out. Hypo/hyper are also accepted as well. I suggest present or absent. When writing it as an outcome, it is best to say “the patient will have active bowel sounds in all four quadrants during pcs.”
- Is it okay to focus on the patient having no edema as an outcome for Ineffective Peripheral Tissue Perfusion?
If you remember, peripheral neurovascular assessment has several assessments: color, temp, cap refil, sensation, pulses, movement but edema is not one of them. The best outcome would be to focus on one of these 5 areas.
- For Impaired Bed Mobility, can you say that the patient will demonstrate optimal independence?
Remember that your outcome needs to be very clear, concise, and measurable. How will you measure optimal independence? Each patient’s optimal independence is different. You could say “the patient will demonstrate optimal independence by using side rails when being assisted to reposition during pcs.” That makes it measurable.
- Can I use “placing call light, phone, and personal items within reach” for an intervention for Impaired Bed Mobility if the outcome is “the patient will be able to direct others on repositioning?”
When you are coming up with interventions, of course, the first thing to ask yourself is “am I assigned?” and yes you would be required to do those things. The second thing you ask yourself is “will this intervention move the patient toward the outcome?” That answer would be no. Those specific things are safety measures that are required of you but that do not help the patient direct others to help them reposition.
- If I am using Impaired Bed Mobility, can I use “the patient will be free from skin breakdown during the pcs?”
You should look at the Nanda as the problem you have chosen to focus on and the outcome as the solution to the problem. Therefore, you should be focusing on the mobility at hand not skin breakdown. If you want to focus on the skin, then you should look at Impaired Skin Integrity or Impaired Tissue Integrity.
- When writing an outcome for impaired gas exchange that says "the patient will have O2 sats of ___% or greater" during the pcs, how do I know what that number should be?
The standard number for a "normal" patient is 95% or greater but if a patient's baseline is not that, like a patient with COPD, then you will be given parameters or a baseline number for them. A couple of things to remember, it is okay not to meet your outcome so when in doubt use the 95% and when they are giving you a parameter on your kardex, that is when you should alert the primary nurse, not necessarily the number you should write as your goal for the outcome so don't be afraid to ask your examiner. Also, in your outcome, be sure to put whether that % is while they are on oxygen and how much or whether that is on room air.
- If I write a care plan for Impaired Gas Exchange and the outcome is that the patient will have O2 sats of 95% or greater while on 2lpm NC during the pcs and I get into the room and their O2 sats are already at 95%, do I have to revise to a risk for?
When a patient is on oxygen and cannot be weaned to room air, then your patient still has a gas exchange problem even though the O2 sats are where you want them. This just means your outcome goal is met. There is not a potential risk, there is still an actual problem so the answer is no.
- If I write a care plan for acute pain and the outcome is that the patient will rate pain a 3 or less on a 0-10 verbal pain scale during the pcs and I go into the room and their pain is a 2 because the primary nurse just medicated them with Tylenol #3, do I have to revise to a risk for?
If the patient is still requiring pain medication, they still have an acute pain problem. It would just mean they are controlled at the moment. Two things need to occur. 1. Be patient and wait because there is a good chance the pain will begin to creep back up during your time with them (If it does not, that is okay.) 2. You need to know how often they are requesting pain medications or receiving it. Getting pain medication around the clock should be that good indicator that you need not to second guess your choice of this care plan and let you know that no you would not have to revise. Now, if they have pain medication available and have not received any in 12 to 24 hours and they are rating pain a 2, at that point, I would revise to a risk for care plan.
- What if I choose to revise to a different intervention and I tell my examiner but the patient refuses that intervention. What do I do?
The great thing about revising (which I am always telling you not to be afraid of) is that you can tell the examiner what you are wanting to do and if it does not work, you just tell them that you changed your mind and you are going to x….y…z….or you can make it easier on yourself and go ahead and work out a few interventions before you even open your mouth to the examiner about revising so that way, you already know what is working!
You just made it through the final part of the 63 CPNE Care Plan questions. That’s determination if we ever saw it. How do you feel? Hopefully you have a better understanding of some of the pitfalls of writing a care plan for the CPNE.
If, however, you still feel like you need a step-by-step care planning roadmap and you haven’t watched my video presentation yet, it’s definitely what you’ve been looking for. Don’t wait until it’s too late. Watch this while there is still time.
Thanks again for letting ATL Clinical Workshop be part of your CPNE studies. We’re always here if you need us. Whether it’s in Atlanta for a CPNE workshop or our Online CPNE Workshop, we’ll get you through it. We’ll do whatever it takes!
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