Clinical Assessment Preparation

CPNE Study Guide

Condition of insertion site Type of flush used Amount of flush (mL)

1. 2. 3. 4.

Patient response to flush Drainage devices, when assigned: Perform the following within 20 minutes after beginning of implementation: • Assess:  Verify type of suction, if applicable  Verify amount of suction, if applicable  Inspect integrity of system 1. Indwelling urinary catheter secured to leg 2. Occlusive dressing to chest tube 3. Ostomy bag secured 4. Nasal gastric tube secured 5. Surgical drain secured  Inspect condition of skin surrounding insertion site  Baseline characteristics of drainage (e.g., quantity, color) a. Type b. Color • Implement: 1. Maintain or attach drainage device to appropriate container 2. Maintain patency of drainage device 3. Ensure drainage device is stabilized 4. Empty drainage device when needed 5. Measure amount of fluid in or removed from drainage device 6. Remove drainage device, when assigned • Evaluate: 1. Patient response to drainage device 2. Patient response to removal of drainage device, when assigned • Document on Fluid Management Flow Sheet: 1. Type of drainage device 2. Site of drainage device 3. Type of suction 4. Amount of suction 5. Integrity of system 6. Condition of skin surrounding insertion site 7. Drainage type 8. Drainage color 9. Drainage amount (mL) within +/- 10% of actual output during planning and implementation 10. Patient response to drainage device 11. Patient response to removal of drainage device, when assigned

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