CPNE Questions

[Medic04]

Where do you find the "Baseline vitals" on your patient?

Also is this alright for the Nursing Process?

Okay say I have a patient that is

Impared Comfort R/T

NPO status AEB patient cannot eat or drink

per doctors orders

GOAL

Patient will be more comfortable during PCS

MET

Patient given mouthcare and sheets adjusted. Pt stated " I am more

comfortable"

Intervention number 1; perform mouthcare

MET

patient assisted with mouthcare. In order to keep muccus membranes

intact and healthy.

Pt stated mouth feels better.

Intervention number 2: assess oral muccus membranes during PCS

MET

Patient allowed assesment of oral membranes during PCS. Muccus

membranes dry.

[EricJRN, MSN, RN]

You'll have access to the patient's chart/vitals flowsheet.

I've been out of EC CPNE matters for almost a couple of years now, but my suggestion on your care plan would be to make sure that your goal is measurable.

[anticoagulationurse]

I think it's a good one. Some goals are measured by subjective statements (like pain and comfort). I like the double whammy of interventions you've got. While providing oral care you'd be assessing mucous membranes too, so why not bang out two interventions for one! Nice work. Now, forgive if I'm incorrect. Wouldn't you want mucous membranes to be moist and not dry?

[EricJRN, MSN, RN]

To clarify my previous post:

My point was just that if your goal is "patient will be more comfortable" - how are you going to decide if it's met or not? I would think more in terms of "pt will state/rate..."

It's a little bit like a pt with difficulty breathing. We wouldn't say "pt will breathe better" even though that's what we want. Our goals involve things like the patient's statements and observable indicators of how the patient is breathing.

Check out this link for more on Impaired Comfort:

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_014.php

[anticoagulationurse]

Ahhhhh, good point. That makes sense to me.