Welcome to part 2 of 3 of the 63 CPNE Care Plan Questions. If you missed part 1 or didn’t save the link you can find it here: 63 CPNE Care Plan Questions Part 1 In Part 2 you will be learning about the top questions regarding interventions that are to be performed when you are in the patient room and how to appropriately incorporate them onto your care plans. Knowing what you are going to do when you get into the room is crucial so remember to save the link to this page to reference back to. Here it is... Part 2.

42.  How do I write an outcome for Impaired skin integrity?

When you choose the Nanda Impaired skin integrity, you should be focusing on an area that is red, blanched, or more superficial and the outcome would be best if focused on the redness. An example for this would be “the patient will have no redness to the gluteal area during the pcs.”

41.  Can you use teaching as an intervention?

Teaching is a wonderful thing, however, you need to be assigned teaching specifically on your kardex to word it as teach as an intervention on your care plan. Effective communication has you teaching all of the time to your patient but just the word “teach” would not be used on intervention unless assigned. We would say “encourage” or “instruct” instead.

40.  Can you use a surgery or surgical procedure like hysterectomy for a r/t or related factor?

The r/t or related factor is what is causing the problem. It cannot be a surgery, surgical procedure, or a person. Just because you don’t put the word “surgery” in the statement, does not give you the okay to use the medical terminology word for the surgery.

39.  Can you describe breath sounds as “regular” or “normal” for an outcome?

Breath sounds are either clear or they are abnormal for this test. When writing an outcome, it has to be very specific, clear and concise, as well as measurable. The best way to write an outcome for breath sounds is to say “the patient will have clear breath sounds in upper and lower lobes bilaterally after interventions during the pcs.”

38.  Why can’t you use the word “maintain” for an intervention but not in the outcome?

Whenever we use the word “maintain” in a statement that means they are already doing it. So if you write “maintain clear breath sounds,” that means the patient already has clear breath sounds which changes the meaning of your care plan to a risk for and not an actual problem. You are not allowed to write risk for care plans during the planning phase.

37.  Can you use “range of motion” in an intervention when not assigned?

When we write range of motion as an intervention, we have to say whether it is upper or lower and whether it is passive or active range of motion. It also must be assigned and you would see it marked on your kardex under musculoskeletal management.

36.  Can you say “perform range of motion to prevent contractures” for an intervention?

Range of motion must be assigned but when it is assigned you have to say active or passive, to upper or lower and interventions should not explain why you are doing it. They are only looking for the action not the explanation.

35.  Can you say “maintain IV fluids” for an intervention?

If you are in charge of IV fluids that is fine but when writing the intervention you need to state the name of the fluid and what rate it is running at. Remember that you have to be very specific in the statement of what you are doing for your intervention.

34.  Can you use “deep breathing” as one intervention and “have patient cough” as a second intervention?

Deep breathing and coughing is one intervention and is not to be split up. You will need an additional intervention that will also move the patient toward the outcome you have chosen. Often positioning upright or incentive spirometry are good choices.

33.  Can you say “provide rest periods before ambulation” for activity intolerance?

Providing rest periods is a good intervention but if they have already been in bed prior to ambulation haven’t they already been resting? Maybe provide rest periods during ambulation.

32.  Can you administer two medications for interventions?

Administration of a medication is one intervention so you pick the medication that will have the biggest impact during your pcs.

31.  If I accidentally leave a word of on the Nanda label, could I possibly make it into the room because the point is still coming across?

This is the easiest thing to do yet one of the most common reasons for failing and not even get into the room. All you do is find the Nanda you wish to use and simply copy it from your Mosby’s book.

30.  How specific do you have to be when writing the validation assessment?

The validation assessment is one specific assessment that you are going to do that proves whether the Nanda problem exists or not. For example, a PNVA encompasses more than one assessment therefore you have to figure out what your focus for the outcome is going to be and that should be what you are assessing like saying palpate pedal pulses instead of PNVA.

29.  Why can’t you use nonskid socks for a mobility intervention since we would fail if we don’t put the socks on the patient?

Nonskid socks are a necessity and a safety measure but according to EC, they do not make the patient actually walk therefore you cannot use nonskid socks as an intervention for any of the mobility Nanda labels.

28.  Is saying “position upright at 30 or 45 degrees” for an intervention acceptable?

The actual degrees for positioning a patient upright are 90 degrees so saying 30 or 45 degrees and upright in the same sentence does not even make sense and is incorrect. Either specify a degree or say position upright but not both in the same sentence. And for auscultating breath sounds they need to be at a 90 degree angle in order to be able to get to the proper landmarks so 30 or 45 degrees would still be incorrect if you choose an outcome about breath sounds.

27.  Can you request for the primary nurse to medicate the patient?

Requesting they medicate with what? You need to be specific on the medication and you need to make sure that they do in fact get medicated during your time with the patient. The problem is that when you are assigned pain management, the examiners are expecting you to personally do something to help the patient’s pain improve. Notifying the primary nurse to medicate is not you doing anything so to me that should be a last resort.

26.  Can you encourage fluids for Impaired gas exchange or for Ineffective breathing pattern?

Interventions should be what you are assigned and it is also wise if you find them in the intervention section of your care plan book. If the interventions are not in your care plan book, you must be prepared to explain how that intervention moves the patient toward the outcome. Encouraging fluids helps loosen secretions so that they can be expelled which is a better intervention for Ineffective airway clearance.

25.  Can you use a gait belt as an intervention for mobility?

When mobility is assigned on your kardex, it will be specified to what assistive devices you are to use so if a gait belt is not on your kardex, you do not use that as an intervention. Follow the instructions and do only what you are told to do.

24.  Can you use “incentive spirometry” as an intervention for Ineffective breathing pattern?

Incentive spirometry is not a listed intervention in Mosby’s for Ineffective breathing pattern. You will have to be able to answer how an incentive spirometer will directly affect the breathing pattern since it is not a listed intervention.

23.  Can you use “incentive spirometry” as an intervention for Ineffective peripheral tissue perfusion?

Incentive spirometry is not listed as an intervention in Mosby’s for Ineffective peripheral tissue perfusion. The goal of the I/S is to open the alveoli in order to promote effective gas exchange but when there is a perfusion issue going on, there is no guarantee that any gas exchange will occur in the periphery therefore not making this intervention valid for this Nanda.

22.  Can you use sequential compression devices for Impaired gas exchange?

This is very similar to the above common mistake but in reverse. Sequential compression devices are to promote blood flow and prevent blood clotting so that the blood flow will make it back to the heart and lungs to be re-circulated and become re-oxygenated. In the periphery, the blood is becoming deoxygenated and not contributing to gas exchange directly. Getting the blood back up to the heart and lungs is very important but is not a direct intervention to help the patient achieve better gas exchange.

Hang in there!

Whew… That’s a lot to study but you’re doing great!

You already know more than a lot of other testers do about some of the common pitfalls of writing a passing care plan.  And we’re not even done yet.  Hang in there though because in our next post we’ll be giving you 63 CPNE Care Plan Questions:  Part 3.

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