Appendix G

Blank Student PCS Response Form

385
2014 Excelsior College. All rights reserved. | November 2014 | 21st Edition
A
p
p
e
n
d
i
x

G
Student PCS Response Form
2014 Excelsior College. All rights reserved.
4
Clinical Performance in Nursing Examination (CPNE)
N
O
V
E
M
B
E
R

2
0
1
4
c
o
n
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i
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e
d

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n

n
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x
t

p
a
g
e
C
P
N
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P
C
S

A
S
S
I
G
N
M
E
N
T

K
A
R
D
E
X

|

P
C
S

#

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
N
a
m
e





M
/
F



R
o
o
m

#





D
O
B





H
o
s
p
i
t
a
l

#



F
o
r

i
n
f
o
r
m
a
t
i
o
n

o
n
l
y






E
x
a
m

s
t
a
r
t

t
i
m
e



I
m
p
l
e
m
e
n
t
a
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i
o
n

s
t
a
r
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t
i
m
e






S
c
h
e
d
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e
d

e
n
d

t
i
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e



T
i
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e

a
d
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d







A
c
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a
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n
d

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i
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e



A
d
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d
i
a
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A
d
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n

d
a
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e





S
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y

d
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t
e



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e
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e



P
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i
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t

s

n
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e



S
A
F
E
T
Y

(
A

c
o
m
p
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o
f

p
h
y
s
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l

j
e
o
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y
)


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r



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o
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e
r





R
e
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s











O
t
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e
r






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i
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N
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d
s


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l
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r
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s







V
i
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o
n







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e
a
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g







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t
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e
r





F
L
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I
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M
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E
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k
e





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u
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W
e
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d
i
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s


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n











F
l
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w

R
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e





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r
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f

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e


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n









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y

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i
b





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a
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e




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e
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s




B
l
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d

p
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e
s
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e



M
a
n
u
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l



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c


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t





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n

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a
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u
r
a
t
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n







L
e
v
e
l

o
f

P
a
i
n


F
L
A
C
C

p
a
i
n

s
c
a
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e


0

5

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e


0

1
0

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s
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O
B
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Y





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e
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t
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d

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A
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s
i
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e







O
t
h
e
r



386
21st Edition | November 2014 | 2014 Excelsior College. All rights reserved.
NOVEMBER 2014 WWW.EXCELSIOR.EDU
Student PCS Response Form
5
Clinical Performance in Nursing Examination (CPNE)
S
E
L
E
C
T
E
D

A
R
E
A
S

O
F

C
A
R
E
A
b
d
o
m
i
n
a
l

a
s
s
e
s
s
m
e
n
t



N
e
u
r
o
l
o
g
i
c
a
l

a
s
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e
s
s
m
e
n
t



P
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i
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r
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l

n
e
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s
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u
l
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r

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s
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e
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m
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n
t





U
p
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r

e
x
t
r
e
m
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e
s





L
o
w
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r

e
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m
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t
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e
s
R
e
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y

A
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m
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t





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n

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a
t
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r
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t
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o
n



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k
i
n

a
s
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e
s
s
m
e
n
t



M
e
d
i
c
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t
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s




S
e
e

M
A
R
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m
e
d
i
c
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t
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o
n




S
e
e

M
A
R


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r
a
v
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y

f

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w
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p

f
a
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t
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r





I
n
f
u
s
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o
n

c
o
n
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l

d
e
v
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e
T
y
p
e




I
n
t
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r
m
i
t
t
e
n
t

v
e
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s

a
c
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e
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d
e
v
i
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e
A
s
s
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e
d

f

u
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h

s
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l
u
t
i
o
n



P
a
t
i
e
n
t

t
e
a
c
h
i
n
g



_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
C
o
-
a
s
s
i
g
n
e
d

w
i
t
h



I
r
r
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g
a
t
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o
n
/
i
n
s
t
i
l
l
a
t
i
o
n





S
o
l
u
t
i
o
n






M
a
i
n
t
e
n
a
n
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e

o
f

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n
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m
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t
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t

v
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e



A
s
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d

f

u
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l
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t
i
o
n



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o
m
f
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r
t

m
a
n
a
g
e
m
e
n
t





C
o
m
f
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r
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i
n
t
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t
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o
n
s


A
d
m
i
n
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m
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d
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c
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t
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n
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(
s
e
e

M
e
d
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c
a
t
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o
n
s
)


A
p
p
l
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c
a
t
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n

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f

h
e
a
t






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p
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t
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n

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f

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o
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d






M
o
u
t
h

c
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r
e

e
q
u
i
p
m
e
n
t




M
u
s
c
u
l
o
s
k
e
l
e
t
a
l

m
a
n
a
g
e
m
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n
t





A
s
s
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g
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e
d

e
x
t
r
e
m
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t
y
(
i
e
s
)






A
c
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e

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f

m
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t
i
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n


P
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a
n
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m
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t
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o
n


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u
p
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e

d
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s






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p
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t
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o
n

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f





H
e
a
t





C
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d


T
r
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o
n


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m
a
n
a
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m
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n
t





O
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y
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n

r
a
t
e





C
a
n
n
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l
a





M
a
s
k





C
r
o
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p
e
t
t
e


O
x
y
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e
n

s
a
t
u
r
a
t
i
o
n




P
a
i
n

m
a
n
a
g
e
m
e
n
t





P
a
i
n

s
c
a
l
e

o
r

a
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e
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s
m
e
n
t

t
o
o
l

t
o

u
s
e






P
a
i
n

r
e
l
i
e
f

i
n
t
e
r
v
e
n
t
i
o
n
s


A
d
m
i
n
i
s
t
e
r

m
e
d
i
c
a
t
i
o
n
s

(
s
e
e

M
e
d
i
c
a
t
i
o
n
s
)


A
p
p
l
i
c
a
t
i
o
n

o
f

h
e
a
t






A
p
p
l
i
c
a
t
i
o
n

o
f

c
o
l
d




R
e
s
p
i
r
a
t
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r
y

m
a
n
a
g
e
m
e
n
t





D
e
e
p

b
r
e
a
t
h
i
n
g





C
o
u
g
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i
n
g


M
e
c
h
a
n
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c
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l

d
e
v
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e
s






C
h
e
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t

p
e
r
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s
s
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o
n






S
u
c
t
i
o
n


W
o
u
n
d

m
a
n
a
g
e
m
e
n
t





I
r
r
i
g
a
t
i
o
n

s
o
l
u
t
i
o
n






W
o
u
n
d

p
r
o
t
e
c
t
i
o
n

S
t
e
r
i
l
e

d
r
e
s
s
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g


C
l
e
a
n

d
r
e
s
s
i
n
g






T
o
p
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c
a
l

P
r
e
p
a
r
a
t
i
o
n




D
r
a
i
n
a
g
e

a
n
d

s
p
e
c
i
m
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n

c
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l
l
e
c
t
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o
n



E
n
t
e
r
a
l

f
e
e
d
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n
g





D
i
e
t

o
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d
e
r






B
o
t
t
l
e

F
e
e
d






T
u
b
e

f
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e
d
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n
g
/
f

u
s
h






C
h
e
c
k

r
e
s
i
d
u
a
l




N
O
V
E
M
B
E
R

2
0
1
4
Appendix G
Blank Student PCS Response Form
387
2014 Excelsior College. All rights reserved. | November 2014 | 21st Edition
A
p
p
e
n
d
i
x

G
Student PCS Response Form
2014 Excelsior College. All rights reserved.
6
Clinical Performance in Nursing Examination (CPNE)
C
l
i
n
i
c
a
l

P
e
r
f
o
r
m
a
n
c
e

i
n

N
u
r
s
i
n
g

E
x
a
m
i
n
a
t
i
o
n

(
C
P
N
E

)

P
l
a
n
n
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n
g

P
h
a
s
e

P
l
a
n

o
f

N
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r
s
i
n
g

C
a
r
e
N
U
R
S
I
N
G

D
I
A
G
N
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S
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M
E
A
S
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R
A
B
L
E

E
X
P
E
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T
E
D

P
A
T
I
E
N
T

O
U
T
C
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M
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N
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R
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I
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G

I
N
T
E
R
V
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N
T
I
O
N
S
1
.

T
h
e

p
a
t
i
e
n
t

w
i
l
l
:
1
.

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h
e

n
u
r
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e

w
i
l
l
:
P
a
t
i
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n
t

a
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s
e
s
s
m
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t
o

b
e

p
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f
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r
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d

v
a
l
i
d
a
t
i
n
g

t
h
e

n
u
r
s
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d
i
a
g
n
o
s
i
s
:
2
.

T
h
e

n
u
r
s
e

w
i
l
l
:
N
U
R
S
I
N
G

D
I
A
G
N
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S
I
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M
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A
S
U
R
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B
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E

E
X
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C
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D

P
A
T
I
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N
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T
C
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S
2
.
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h
e

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a
t
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e
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t

w
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l
:
1
.

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h
e

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u
r
s
e

w
i
l
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:
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a
t
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e
n
t

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s
s
e
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s
m
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t
o

b
e

p
e
r
f
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m
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d

v
a
l
i
d
a
t
i
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g

t
h
e

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r
s
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d
i
a
g
n
o
s
i
s
:
2
.

T
h
e

n
u
r
s
e

w
i
l
l
:
388
21st Edition | November 2014 | 2014 Excelsior College. All rights reserved.
NOVEMBER 2014 WWW.EXCELSIOR.EDU
Student PCS Response Form
7
Clinical Performance in Nursing Examination (CPNE)
C
l
i
n
i
c
a
l

P
e
r
f
o
r
m
a
n
c
e

i
n

N
u
r
s
i
n
g

E
x
a
m
i
n
a
t
i
o
n

(
C
P
N
E

)

R
E
V
I
S
E
D

P
l
a
n
n
i
n
g

P
h
a
s
e

P
l
a
n

o
f

N
u
r
s
i
n
g

C
a
r
e
N
U
R
S
I
N
G

D
I
A
G
N
O
S
I
S
M
E
A
S
U
R
A
B
L
E

E
X
P
E
C
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Appendix G
Blank Student PCS Response Form
389
2014 Excelsior College. All rights reserved. | November 2014 | 21st Edition
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Student PCS Response Form
2014 Excelsior College. All rights reserved.
8
Clinical Performance in Nursing Examination (CPNE)
C
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390
21st Edition | November 2014 | 2014 Excelsior College. All rights reserved.
NOVEMBER 2014 WWW.EXCELSIOR.EDU
Student PCS Response Form
9
Clinical Performance in Nursing Examination (CPNE)
DATE
MEDICATION ADMINISTRATION RECORD (MAR)
Medication / Dosage / Route / Time Initial when given
Signature Initials
Patient name
Date of Birth Med Record #
Allergies
NOVEMBER 2014
Appendix G
Blank Student PCS Response Form
391
2014 Excelsior College. All rights reserved. | November 2014 | 21st Edition
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Student PCS Response Form
2014 Excelsior College. All rights reserved.
10
Clinical Performance in Nursing Examination (CPNE)
PCS Recording Form
The student will record:
1. All information required by the specifc critical elements as listed under the shaded areas of care.
2. Nursing care performed for all assigned required and selected areas of care.
3. Any observation of the patients condition that could infuence subsequent care.
Recording Directions:
Describe all assessment fndings and nursing care performed by the areas below that apply.
Medications should be recorded on the medication administration record (MAR).
Fluid Management
Enteral intake (amount) Parenteral intake (type and amount) Output (type and amount)
Hydration status (choose one)
Skin turgor

OR
Mucous membrane

OR
Fontanel

Parenteral fuids
Current solution

ICD setting
OR
Calculated drops/minute
Condition of IV site
Temperature
OR
Edema
New Solution

Condition of IV site when IV discontinued

Intermittent venous access
device maintenance
Condition of IV site
Temperature
OR
Edema
Flush (type and amount)

Intravenous Medications
ICD setting
OR
Calculated drops/minute
IV site
Temperature
OR
Edema
Flush (type and amount)

Mobility















Vital Signs
First Set Second Set
Temperature
Pulse Rate
Respirations
Blood pressure
Weight
Oxygen
saturation
Level of pain
Enteral Feeding
Kind of feeding
Rate of feeding
Pump setting
Amount of feeding
Gastric residual amount

392
21st Edition | November 2014 | 2014 Excelsior College. All rights reserved.
NOVEMBER 2014 WWW.EXCELSIOR.EDU
Student PCS Response Form
11
Clinical Performance in Nursing Examination (CPNE)
Narrative Nurses Notes
Document the pertinent patient data including all related assessment fndings for
Assigned Areas of Care not included on the previous page of the Student PCS Response Form.
Write your assessment results from the original Planning Phase Plan of Nursing Care, and if using the
Revised Planning Phase Plan of Nursing Care, only if the assessment is not documented as part of another
assigned area of care.
Assessment Results for Nursing Diagnosis #1
Assessment Results for Nursing Diagnosis #2
Assessment Results for Revised Nursing Diagnosis/Diagnoses
ABDOMINAL ASSESSMENT





COMFORT MANAGEMENT





DRAINAGE AND SPECIMEN COLLECTION





Appendix G
Blank Student PCS Response Form
393
2014 Excelsior College. All rights reserved. | November 2014 | 21st Edition
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Student PCS Response Form
2014 Excelsior College. All rights reserved.
12
Clinical Performance in Nursing Examination (CPNE)
IRRIGATION/INSTILLATION





MUSCULOSKELETAL MANAGEMENT





NEUROLOGICAL ASSESSMENT





OXYGEN MANAGEMENT





394
21st Edition | November 2014 | 2014 Excelsior College. All rights reserved.
NOVEMBER 2014 WWW.EXCELSIOR.EDU
Student PCS Response Form
13
Clinical Performance in Nursing Examination (CPNE)
PAIN MANAGEMENT





PATIENT TEACHING





PERIPHERAL NEUROVASCULAR ASSESSMENT





RESPIRATORY ASSESSMENT





Appendix G
Blank Student PCS Response Form
395
2014 Excelsior College. All rights reserved. | November 2014 | 21st Edition
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Student PCS Response Form
2014 Excelsior College. All rights reserved.
14
Clinical Performance in Nursing Examination (CPNE)
RESPIRATORY MANAGEMENT





SKIN ASSESSMENT





WOUND MANAGEMENT





396
21st Edition | November 2014 | 2014 Excelsior College. All rights reserved.
NOVEMBER 2014 WWW.EXCELSIOR.EDU
Student PCS Response Form
15
Clinical Performance in Nursing Examination (CPNE)
OTHER OBSERVATIONS