My CPNE experience in Atlanta

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Here's my CPNE experience: Atlanta, GA

Overall: It was a hard exam but doable. The CA and the CEs are nice and they want us to pass. I think they are frustrated too when they see something is wrong or about to go wrong but they can't tell us. But if you are smart, you should be able to observe them for clues too. Believe me, by observing their facial expressions or body languages, you can prevent disasters. When you are about to do something (or about to forget to do something), they may be looking at a piece of equipment or an area because this is what they expect to watch you do next. We had 7 students and 7 CEs and separated into two groups. All CEs in my group are very nice and cooperate with us. Making sure you tell the CE what you are doing such as "I AM GOING TO START BY WASHING MY HANDS !" Anything you want the CE to hear, say it out loud. Sometimes, you can exaggerate your talking to the pt a bit just to really tell the CE what you are doing. Use the alcohol hand wash as often as you wanted but surely exaggerate that you look at your hands for no observable soiling. Get your nerves in control and you should be fine.

Preparation:

I read the EC study guide and made flash cards from the first couple of pages of each section on critical elements. I read it over and over and dictated them back on paper. For those that I missed, I wrote them out again in red ink to remind myself. I didn't use mnemonics because it doesn't work for me and the phases don't click. I believe if I understand why I need to do those CEs, I should be able to carry out what I need to do. I bought the DVD and watch it over and over again and made a mental picture out of it. I didn't use skill bags or any preparation class. I didn't join any ECN chat sections but I read old transcripts (especially those recent ones). The old transcripts are very difficult to read because everyone in the chat room basically screamed out their questions so the instructors were trying to answer multiple questions at the same time. Sometimes, I found the answers contradict each other in different chat sessions. The transcripts helped in some ways but it also cause confusions in other ways so use it with cautions. The critical elements are overwhelming but most of the time only a few applies. You are only to apply those that are CHECKED in the kardex. For ex, I didn't have I&O checked in my first PCS so I didn't need to measure fluid I&O but I had to complete other fluid mgn elements such as checking skin turgor. For labs, I have watched enough IVP in work place and I do IVPB with ICD at work so that wasn't problem for me. In fact, I do gravity drips at work for IVPB on my patients. I like it better is because for one is I can practice, for two there is no pump beeping at me when it is finished. We rarely mix insulin at work but I have done it before so that's fine for me. Wound is the area that I rarely do nor was I taught enough at LPN school so preparation for the wound station was entirely from the DVD. What works for me in lab is to mentally reheorifice everything from the DVD over and over. My total preparation time was about a month.

DAY 1: Trip, hotel and hospital:

I drove to test site on Friday. It was first started out ok but then it rained after 1200 and Atlanta traffic is terrible. I thought I would arrive the hospital at 1430 but ended up getting there at 1515. Still not bad. There were already two of us there when I arrived (you can tell who they are - EC stuffs, reading notes and holding the NDx handbook etc). If you can afford an extra night of hotel, I recommended getting there a day earlier. I basically sat there and unwind from the driving stress and ate a snack. I used this time to focus and regroup myself rather that scanning my notes at the last minutes. Due to the NASCAR race at the same weekend, I couldn't book any of the hotel they recommended but I ended up in Holiday Inn Airport North. Weekend traffic is no problem and it's only 15 mins to hospital and the room is quiet. Other students complaint about their hotel mostly noise level. So at 1600, the CA arrived and took us down to the room where we signed in, ID checked an got our name badge. The CA read the scripts as exactly in the study guide. We were then oriented into the lab and the setup is the same as the DVD. However, the lab is very small. Then the CEs arrived and they introduced themselves (all) in less than 10 seconds. Then we were called into the stations to start the exam.

LABs:

First one was IVPB. It was easy, only took me 10 mins. Had my calculation recheck 3 times. The only thing it took me long is to adjust the drip rate because the roller has been on the same tubing for possibly very long so I either shut the whole thing completely off or it runs too fast. So, I move the roller into a different location on the tube and I was able to control the flow rate. Took me 3 mins to adjust the flow rate. Passed!!! One of us failed this one because she forgot to lower the primary bag and was adjusting the drip on the pri bag instead of the piggy bag. Nerve control is everything !

Second one was IVP: I calculated the amount to be drawn and the ¼, ½, ¾, check point and wrote it below the calculation. Drawn up the flush and set them aside with exaggeration. Then I draw up the med. I had a bubble that I couldn't get rid of so I told the CE I'm going to discard it and start all over drawing the med. I succeeded the second time with no bubbles. When I draw the flush and the med, I pay attention only to touch the parts of the syringes that I am supposed to or I will contaminate it. Put gloves, checked IV site, ID pt, etc and start connecting the flush, aspirated and push the flush, then med, then final flush. When I pushed the med, I made sure no more than the calculated amount will push faster then the time marker. My push for the med was right on time at the one minute marker (I don't recommend you do the same, slower will not fail you but faster will). Passed !!!

Third one was Insulin SC. This one was also easy. I just had to make sure I do it slow and not over drawn anything. I was very careful to draw up the meds and making sure I didn't touch the part of the syringes that I'm not supposed to. I showed the CE all the amount of air and insulin drawn. Then ID pt, put gloves on, alcohol whipped and injected. Passed !!! I think one of us failed this lab because she forgot to put gloves on during injection.

Last one is wound. I did everything the same way as the DVD. After I finished, the CE asked to speak to the CA. So I was stunned ! The CA checked and said that I had done it correctly and I passed !!! This CE didn't do my PCS. Another student also told me this CE picked on her packing too. I think the problem with this is the dummy is actually much smaller than the pic shown in the study guide and you could easily over pack and touching the surrounding skin which can cause a fail.

FLOOR orientation and first assignment:

My first CE took me to the peds floor and gave me a very brief orientation. Basically, there is not a whole lot you need to know about the floor because the CE will get things for you. My first assignment was a 16 years old F with a I&D procedure. My AOC was VS with pain ass, Fluid, ambulate, neuro, abdominal ass, med (IVPB), wound wet to dry dressing change (yeah, right, again). So, I looked at the chart, wrote down orders (especially wound care), base line VS, labs, previous shifts nurses notes and went back to hotel and did my care plan.

DAY 2:

PCS1 : AOC as noted above. My NDx were acute pain and impaired tissue integrity. Passed the planning phase and started working. (At that time, they changed my meds, the RN had to give the med that I was supposed to give and I had to hang another IVPB at a different time.) I went in, introduced myself and instructor, ID pt, checked IV fluid, site, documented then I was about to start my VS. For IV, the RN started her IVPB and it ran at 100/hr instead of the 200/hr as in the MAR so it will push my IVPB time behind. The CE knew it. Another thing is when I first checked the IVF, it was running the RN's IVPB. So I document the base solution of that med and also stated it was running IVPB over NS at that time to cover myself. For VS, the machine was broken so we had to find another one. Got this done and moved on to neuro, an easy one. When you do neuro, making sure you check strength bilaterally at the same time. One of use failed neuro by doing it one side at a time. If you do one side at a time, you have no way to compare for equal strength. Then I moved on to abd assessment. She has an abdominal dressing but I was still able to do all 4 quards. Then I went outside, do some charting, returned to room for IVPB. The ICD has a different port for PB so it is not needed to lower the pri bag. Connected the bag, set rate, rechecked IV site, ID patient again and start pump. Signed my name on hospital MAR. Then I saved my least favorite part for last - wound. After my CE talked with the RN, she added irrigation to the kardex. The MD's order specified irrigated with H2O2 and wet to dry dressing. But somehow the RN translated to irrigate the wound with ½ NS and ½ H2O2. When I looked at the bottles both full strengths. I looked at the CE and she said she can't teach me. But I managed to mixed 20ml of NS with 20ml of H2O2 and that final solution is therefore ½ NS and ½ H2O2. Got all my stuffs setup and irrigated the wound using a syringe. The CE helped me to pour NS onto 4x4 since I was already on sterile glove (nice). I then packed the wound with the gauze using q-tips. Placed abd pad on top, taped and signed. Cleaned up and said so long to pt and went back to charting. My CE gave me 5 mins for extension and I used up all the time. It was mostly due to the changes and the additional irrigation that made it hard. Also, the wound area is my weakest link. I was back to my room waiting and the CE came back to me after a while and said I passed !!!

PCS2:

I was back to the waiting room and it was about only 20 mins I was called by my 2nd CE for another PCS. The pt was an older lady S/P TAH with morphine PCA. NDx were acute pain and ineffective air way clearance. AOC were fluid with I&O, VS, ambulate OOB to chair, neuro and resp management with deep breath and coughing, IS x10. Everything with this pt went well except I couldn't get her pain level on the scale. Everytime I asked, she always said pain varies even when I ask her to tell me her pain level at that moment. So I had to chart by observing pt's behavior. Her deep breathing is shallow and cough is weak and refused IS. The patient needs to be reinforced about using PCA pump and so she pushed the button a few times. In the middle, the MD came in and check pt and told her she will be going home. I think this helped the pt. The MD raised the bed and forgot to lower it back when he left so I promptly lowered it after the MD left and voiced it to the CE to show my consciousness of safety.At the end, she drank the entire cup of water I started at the beginning and I assisted her to the bathroom and I promptly claimed these are I&O and OOB to chair. So, when she was back to the bed and sitting at the bedside after pee, she started to talk and gave me lots of words for encouragement. I then claimed this in documentation as the care plan is effective per patient's behavior at the end of PCS. After documenting everything (including those that patient refused and CDM invoked), handed the paper to the CE and was told I passed after she checked it.

So, I went back to the hotel happily knowing I had one more to go. I was able to watch some TV and had a better sleep. Also, the time change gave me an extra hour of rest.

DAY 3:

PCS3: I started out with a patient and got my care plan all ready and passed the planning phase then the pt was taken to EGD and the CE stopped the process and gave me another pt so I had to start all over. This original assignment included IVP protonix 40mg mixed with 10ml NS and 1ml NS flush before and after.

This pt is an older lady with gastroenteritis. AOC were, I&O, BR with BRP, SRx2, VS with SaO2 and pain, abd assessment, comfort mgn, Muskeletal - A ROM. No meds. Got my planning phase complete with NDx of Altered comfort and acute pain. Did the first 20 mins stuffs and started assess pain level and the pt said 10 of 10. Of course, I told the CE I'd go tell the RN immediately and so I did. The RN said every time this pt will say pain of 15 and the pain med was given about 1.5 hours before PCS started and it's Q6h. So, I went back and related this information to pt. I continue to access VS, the teaching stethoscope is of low quality and I had hard times hearing BP so I did it twice and slow and got through. Then the abd assessment. She really didn't have much bowel sound at both lower quad but normal at upper. I took much longer time to listen to lower and the CE just dropped her ear pieces and let me listen by myself. After that, I did voice to the CE that the lower quads are hypo. Then I moved on to A ROM. After a few "one-more, two-more", the pt C/O of pain in shoulders so I invoke CDM and abort the AROM. Then I moved on to comfort and offered face waching, oral hyg, back rub and reposition and all were refused. Finally, I gave her some water to drink and told the CE how much was it. Also, she has a diaper so it takes care of the output. I thank the pt and left the room for my documentation. Since there were many areas refused by pt so I had to documented in a different way and put all this down and stated the goal not met and documented all the actions, things offered and the pt's refusal. I rechecked my paper 3 times for all documentation and put adult diaper in the output box and it took care of the business and I passed !!!

Back to the waiting room, the CA came and congratulated me. She did chatted with me a little bit and asked what will be my next step.

Hope this helps. I may be adding if I can remember things later. But that's all for now.

-AC :balloons: