Greetings!

Below is a compilation of the practice scenarios I posted over the last few months. Please feel free to use these for practice. I wish you all the best in your preparation for the CPNE.

-Chuck

Tori Rivers is a ten-year-old female, admitted for severe right lower quadrant pain and fever. A CT scan confirmed appendicitis. She is one day post-op. She is allowed out of bed to the chair. When getting out of bed, she walks bent over holding her incision and grits her teeth as she sits down. She is receiving Tylenol and codeine for pain, and is receiving Cephradine PO for antibiotic. Her last dose of codeine was 2 1/2 hours ago and she is soon due for her Tylenol. Her incision is clean and the dressing needs changed today. A Foley catheter is in place.

Areas of Care:

* Fluid Management - I&O

* Vital Signs - BP, AP, RR, T (oral), Pain

* Safety/Other - SR up X2 while in bed

* Mobility - OOB to chair

* Wound Management - DSD to incision

* Drainage/Specimen Collection - Foley catheter

* Pain Management - Pain med plus one intervention

* Medications - Tylenol 240mg po; Cephradine 300mg po

Ms. Vicki Ledel is a 52 y/o female admitted four days ago for a right knee replacement due to aseptic necrosis of the lateral condyle. Her surgical procedure was uneventful. She is currently on a continuous passive range of motion machine (CPM). Ice is being applied to her right knee for 30 minutes three times a day. Her dressing remains intact with no new drainage. Her IV antibiotic has been discontinued and she is now receiving oral antibiotics. She is on a regular diet and tolerating food well. She is taking in adequate fluids and urinary output is quantity sufficient. She is presently having regular BMs, but her elimination is being monitored closely, as she is taking Lortabs 5mg po Q4 hours prn for pain (and has been taking them Q4 hours while awake). Physical therapy has made an initial assessment. Two-person transfer and limited weight-baring with a walker has been initiated.

Overriding/Required Areas of Care:

* Safety/Other (SR up X2, eyeglasses, dentures, TED hose bilateral lower extremities continuous)

* Mobility (Transfer OOB to chair with assist of 2 and walker, limited weight-bearing of right leg; elevate RLE while OOB)

* Vital Signs (BP, AP, RR, T, Pain)

Selected Areas of Care:

* Peripheral Vascular Assessment (lower extremities)

* Muskuloskeletal Management (AROM of LLE, PROM of RLE; CPM to bilat legs while in bed; Cold application to right knee X 20 minutes)

* Pain Management

* Respiratory Management (cough/deep breathing)

36 yo female s/p cholecystectomy, 2 days ago. Right abdominal incision with DSD. JP drain in place, being removed after lunch. Indwelling Foley catheter. Fluctuating pain levels 5-9 on 0-10 scale and maintains morphine PCA at this time.

Siderails x2

VS – P, R, BP, T, Pain level 0-10 scale

Fluids – IV D5LR, 120 ml/hr.

I&O

Mobility: Ambulate hall x1 with assist, OOB to chair ad lib

AOCs:

Respiratory Management – IS x10 every hour

Abdominal Assessment

Comfort Management

Wound Management – DSD to abdominal incision

31 yr old male admitted 4 days ago for altered level of consciousness, tachypnea and polyuria. Recently diagnosed with NIDDM. He has been upset by the diagnosis and believes there is a mistake. BGL has been regulated with oral hypoglycemics and diet changes. He has not been in any pain, but is very restless and anxious. His significant other recently brought in relaxation tapes “to help calm the patient’s nerves”.

VS – BP, P, R, oral T

IV heplock right wrist

Mobility – OOB ad lib

AOCs:

PVA

Neuro Assessment

Comfort Management

Medications – Avandia 4mg PO 0900 (co-assigned with patient teaching)

12 yr old female admitted 2 days ago for hemorrhage s/p tonsillectomy. She is on clear liquid diet and tolerating fluids well. Lab values this morning unremarkable and within normal ranges. Parents are in the room and very anxious about their daughter’s condition. This causes patient some related anxiety. Patient has not been in pain for >24 hours. Patient has NG tube, clamped at this time.

SR x2

VS – BP, P, R, Temporal Temp, SpO2

IV D5LR 75 ml/hr

Hourly I&O

Mobility – OOB to chair ad lib; Ambulate down hall x1 with assist

AOCs:

Abdominal Assessment

Comfort Management

Respiratory Assessment

Neuro Assessment

13 year old male admitted a week ago after being stabbed in the head with a butter knife. Is now in step-down unit waiting for discharge. Per parents has been acting “more like himself” and “really seems to be coming around”. States he still has severe headaches now and then, especially when first getting up from bed. This morning was rated as 6/10. He is steady on his feet, but tends to veer to the right side when walking. Denies having weakness or dizziness.

VS – P, BP, R, oral temp, pain level 0-10 scale

IV – NS 100 ml/hr, gtt factor 15, encourage fluids

Mobility – Ambulate hall x1 with assist

AOCs:

Neuro assessment

Respiratory assessment

Comfort management

17 year old male waiting for discharge to tertiary facility. Was admitted 4 weeks ago for epidural hematoma after falling from his skateboard and striking his head on the sidewalk. Aspirated belly contents en route to hospital and developed pneumonia. Patient has thick, clear secretions when coughing and requires occasional suctioning. PEG tube in place. Parents administer intermittent feedings at bedside, last one about 90 minutes ago. Trach in place with 40% humidified oxygen by Venturi mask.

VS – AP, BP on left arm, P, SpO2

IV – PICC line (heplocked) right UE

Mobility – reposition in bed x1

AOCs:

Neuro Assessment

Abdominal assessment

Skin assessment – sacrum

Respiratory management – sterile suctioning x1

19 yo female s/p MVA last week. Was admitted for compound fracture of her right humerus. Opted for external fixator in lieu of ORIF. On post-op day 2 suffered a left sided CVA from fat emboli. Today presents with right sided weakness. Uses PCA dilaudid PRN for pain. Indwelling Foley catheter.

SRx3 (2 up on right)

VS – AP, BP (on left), R, oral temp, pain level

IV NS with 20 meq KCl 85 ml/hr on ICD

Mobility - Reposition in bed x1, right arm on pillow

AOCs:

Neuro assessment

Skin assessment – right elbow

Comfort management

Respiratory management – C&DB x3, IS x5

27 yo male admitted 2 days ago for fractured left femur. Currently in skeletal traction to the left leg. Foley discontinued this morning due to UTI. Patient voids in urinal/bedpan PRN. Trapeze in place and patient strong enough to assist with movement.

VS – P, BP, R, T, Pain level

Mobility – Bed rest, reposition x1 with assist

Fluids: IV NS 125 ml/hr

Medications: Colace, Dilaudid PCA, multivitamin, Bactrim

AOCs:

Neuro Assessment

Skin Assessment – include left leg in traction straps

Respiratory Management – IS x5 qhour

Musculoskeletal Management – traction, AROM to right LE


This was an emergent patient. So it's been "modified" to protect the innocent and make it usable for a practice scenario....

29 yo female admitted 3 days ago with intractable lower abdominal pain. Newly diagnosed with endometriosis. Progressively more ambulatory, but complains of cramping with prolonged movemet. When pain is "bad" she tends to hyperventilate.

VS - AP, P, BP, oral temp

IV - D5NS 100 ml/hr by gravity, 15 gtt drip factor

Mobility - Ambulate hall x 1 during PCS

AOCs:

Abdominal assessment

Comfort Management

PVA

Medications


31 yr old male admitted three weeks ago for multiple traumatic injuries following a snow tube accident. He was bedridden in ICU for 12 days. PEG tube in place for bolus feedings. He has been improving the last few days and is pending discharge to the local rehab facility tomorrow. He is awake, alert, and oriented, but unable to speak due to the tracheostomy. Humidified oxygen is maintained at 30%. PT has him up twice a day, but he continues to fatigue easily.

VS – AP, BP, R, temporal temp

Mobility – OOB to chair with assist

IV D5NS 100 ml/hr

AOCs:

Comfort Management

Abdominal assessment

Respiratory Management – suction PRN, SpO2

PVA

Musculoskeletal Management – AROM lower extremities

32 yr old female s/p left wrist ganglion cyst removal 1 day ago. Admitted to unit because of intractable pain. Wearing rigid splint on left hand/wrist. Patient is left hand dominant. Morphine q4h PRN for pain.

VS – BP, P, Oral temp, R

Mobility – OOB ad lib

IV NS KVO right forearm

AOCs:

Skin assessment – left wrist

Musculoskeletal management – AROM upper extremities (without splint), ice to left wrist

PVA – upper extremities

Comfort Management

Medications – ibuprofen 800mg PO 0900

38 yo male with PMHx for smoking 1½ packs of cigarettes per day for 20 years. Admitted with complaints of shortness of breath and chest tightness. Has a non-productive cough and expiratory wheezes. Oxygen 2 lpm NC,

VS – P, BP, R, oral temp

Mobility – OOB to chair ad lib, ambulate hall x1 with assist

AOCs:

Respiratory Management – C&DB x5, IS x10

Medications – Atrovent nebulizer 0900

Specimen collection – sputum

Comfort Management

3 year old female patient admitted 3 days ago for 1st/2nd degree burns to both legs (28% BSA). Multiple blisters to both lower legs, some of which have broken open today. Pain has been 4-5 on FACES scale. Parents at bedside. “She is really scared. So many people have been in here she doesn’t want to deal with anyone”.

VS – AP, BP, R, oral temp

IV D5LR 60 ml/hr on ICD

I&O

Mobility – OOB to wagon and around unit x1

AOCs:

Abdominal Assessment

Comfort Management

Wound Management – Silvadene cream to lower left leg, covered with DSD

42 year old male s/p left below-knee amputation following a horrific car crash. Is waiting for discharge to rehab facility. “I guess I had to make a choice about living or dying. It sucks that I lost my leg, but at least I’m still here”. Pain is 4/10 in left leg. Has been on PCA dilaudid. Switched to oral oxycontin q 6 hrs PRN this morning. Last dose 4 hours ago. Large, bulky dressing over amputation site.

VS – BP, P, R, oral temp, pain level

IV – NS KVO left forearm

Mobility – OOB to wheelchair, move chair around unit x1

AOCs:

PVA – lower extremities

Respiratory management – IS x10

Abdominal assessment

Comfort management

42 yr old male admitted for intractable abdominal pain associated with a 20 pound weight loss. Diagnosed with Crohn’s disease 3 days ago. Diarrhea x5 in last 24 hours. Labs this morning show Hgb is 10, Hct is 33, elevated BUN. Oxygen 4lpm NC with humidification. NG tube removed this morning. Now on clear liquid diet. Complains of “extreme” fatigue and “crampy” abdominal pain 4/10.

SR x2

VS – AP, BP, oral temp, R, pain level 0-10 scale

IV NS 150 ml/hr by ICD

Strict I&O

Mobility – Bed rest with HOB > 30 degrees at all times, bedside commode PRN

AOCs:

Abdominal Assessment

Respiratory management – IS x10, SpO2

Skin assessment - perianal region

Comfort Management – mouth care with toothpaste & brush


43 yo male admitted to floor for cellulitis of LLE with some “breaks” in the skin. PMHx for DM, morbid obesity and hypothyroidism. Suddenly stopped taking insulin 2 weeks ago when his wife left to take care of her mother. This morning complaining of pain 5/10 with ambulation and hesitates to get out of bed because of it.

VS – AP, BP, R, T, pain level 0-10 scale

Mobility – OOB to chair ad lib.

IV NS 100 ml/hr on ICD

Medications: Synthroid, insulin, meperidine q4h PRN for pain

AOCs:

PVA – lower extremities

Skin assessment

Wound Management – DSD to left lower leg

Comfort Management


Patient is 44 y.o. widowed female. Admitted 4 days ago with respiratory distress. Continues with intermittent non-productive cough. Resides in long term facility. Has a cleft palate and some expressive aphasia.

IV: IVAD to R wrist;

VS - AP, BP, R, T

O2: 2L via NC;

Strict I&O. Indwelling Foley catheter

Mobility: Siderails x4. Ambulate with assist as tolerated.

AOCs:

Comfort management: mouth care

Specimen collection: urine

Respiratory Management - C&DB, IS x5

Neuro assessment

54 yr old male admitted to Neuro floor earlier today. Was in ICU for a week s/p ventriculostomy for a subdural hematoma. Small gauze pad to left occiput. PMHx significant for HTN, NIDDM, hyperlipidemia, and asthma. Heplocked central line right subclavian. IV NS 67 ml/hr on ICD infusing into peripheral line in left hand. Denies pain since day 2 post-op, but has some generalized weakness. Wife and son at bedside

SR x2

VS – AP, P, R, BP (right arm)

Mobility – Ambulate to waiting room x1 with walker assist

AOCs:

Neuro Assessment

Skin Assessment

Respiratory Management – IS x5, no coughing

Comfort Management

61 yr old female admitted for severe abdominal pain and diarrhea. Recently returned from a cruise where she was overindulged in various foods. Loose stools x4 in last 18 hours. Cramping abdominal pain rated 7/10 this morning upon rising. PMHx significant for celiac disease and osteoporosis.

VS – P, BP, R, oral temp

IV LR with 20 meq KCl – 100 ml/hr on ICD

Strict I&O

Mobility – OOB to chair x1 during PCS

AOCs:

Abdominal assessment

Skin assessment – perianal

Pain management – Bentyl PO 0900

Specimen collection – stool

61 yr old male admitted for chest pain and respiratory distress. He is easily fatigued and exhibits purse tachypneic, lipped breathing with mild exertion. Oxygen 4lpm NC. PMHx significant for systolic murmur, emphysema, Hepatitis C, and HTN.

VS – AP, BP, oral T, R,

IV NS 86 ml/hr

Mobility – Dangle legs x1, HOB >30 degrees at all times, BR privileges with assist

AOCs:

Respiratory management – with SpO2, C&DB x5

Comfort Management

PVA

Skin assessment

Medications – Spiralactone PO, atenolol PO, methylprednisolone PO 0900

66 yr female patient admitted 2 days ago for rotator cuff injury. Scheduled as outpatient but admitted for hypoxia post surgery. Right arm is immobilized with sling/swathe. Patient is right hand dominant. Her pain is controlled at level 2, but intermittently spikes to 7-8/10. Yesterday she started to have an intermittent cough. This morning 2+ pedal edema was noted bilaterally. Morning labs show Na+ of 151.

VS – P, BP, R, T, Pain level on 0-10 scale, SpO2

Mobility – OOB to chair x1 with assist,

IV – D5LR 75 ml/hr.

I/O: Strict

Meds: HCTZ, Morphine 5mg PRN, Boniva

AOCs:

PVA – upper extremities

Abdominal assessment

Comfort Management – mouth care

Respiratory Management – IS x10 q hour

Drainage – Right UE Hemovac drain

70 yr old female admitted two days ago with dehydration/ gastroenteritis. Alert, but disoriented to time. Wearing Depends for uncontrolled incontinence of stool. Complains this morning about fatigue. PMHx significant for dementia, Afib, osteoporosis and HTN. She continues to pass multiple liquid stools.

SR x2

VS – Oral temp, AP, BP, R, weight (complete orthostatics x1 before ambulation)

I&O – encourage fluids

IV – D5 ½ NS with 20 meq KCl at 67 ml/hr by ICD

Mobility – Ambulate to nurses station x1 with assist, OOB ad lib

AOCs:

Abdominal assessment

Skin assessment

Medications - KCL 40 Meq po at 0830

Comfort management

74 yo male admitted for squamous cell carcinoma of esophagus. Pain 0/10. Denies having nausea or diarrhea. However reports severe fatigue and weakness. On soft liquid diet. Scheduled for esophageal surgery in 2 days.

VS – P, BP, R, oral temp

IV heplock left AC

Fluids: Encourage in addition to liquid diet

Mobility – OOB to chair x1 with assist

AOCs:

Respiratory Assessment

Comfort Management

Musculoskeletal Management – AROM upper extremities

Neuro Assessment

The patient is an 8 years old who underwent a right inguinal hernia repair three days ago. Sutured incision right inguinal area covered with sterile ABD pad. Drain was removed this morning. Requires DSD at 0830. Is reluctant to cough because of pain. He points to FACES level 3 with any movement and FACES level 5 with coughing. MSO4 q 4 hours for pain.

SR x2

Vs – AP, BP, R, Tympanic temp, pain level FACES scale

IV NS 60 ml/hr. Gtt factor 15 ml/gtt

Mobility – Ambulate to play room and back x1 with assistance

AOC:

Pain management – ordered MSO4 0900

Respiratory management – C&DB x3, IS x5

Wound management – DSD to inguinal incision, cleanse skin with H2O

Abdominal assessment

27 y/o male who, over the last year, has steadily gained weight, especially around his waist. After being diagnosed with Cushing’s Disease he attempted weight loss with a variety of OTC “remedies”. As a result he has liver failure and has been admitted for a liver biopsy. Has acute ascites, which is causing some dyspnea. Oxygen 2lpm NC. His extremities are atrophied. Has some abdominal pain, last rated 4/10 and constant. Fentanyl ordered PRN for pain.

VS: AP, BP, R, oral temp, SpO2

IV: D5NS 65 ml/hr

I&O: Restrict oral fluid to 300 ml during PCS

Mobility: OOB to chair with assist, ambulate down hall x1 as tolerated with assist

AOCs:

Abdominal assessment – girth measured at level of umbilicus

Respiratory management – IS x10 qhour

PVA – lower extremities

Comfort management

Mrs. Crow is a 70 year-old white female with a history of early Alzheimer's Disease. She is widowed and lives alone. She fell at home and fractured her right hip. She was brought to the E.D. two days after the fall with severe pain. An open reduction internal fixation was done two days ago. She experienced urinary retention 24 hours post-op and a 16 Fr Foley catheter was inserted. The urine was cloudy with several mucus plugs noted in the tubing. She is oriented to person and place, but not time. She has an order for Tylenol with codeine every 4 hours prn for pain. Her most recent dose was 2 hours ago.

Areas of Care:

* Fluid Management - I&O

* Vital Signs - BP, RR, HR (radial), T (oral)

* Safety/Other - SR X2 up at all times, TEDS continuously

* Mobility - Out of bed with therapy only; reposition X1

* Irrigation - Irrigate F/C with 50ml NS to a closed system

* Musculoskeletal Management - Abductor pillow at all times; AROM of bilateral upper extremities

* Comfort Management - 3 comfort measures