Clinical Assessment Preparation

CPNE Study Guide

• • Inspect that IV dressing is intact Assess tubing is secured • Assess IV tubing is free from kinks and air • Evaluate patient’s response to IV fluids • Document findings on fluid management flow sheet Drainage Devices when assigned on Kardex- Remember to assess and document within 20 minutes of starting the Implementation Phase • Verify type of suction if ordered • Verify amount of suction if ordered • Inspect integrity of system o Indwelling catheter secured to leg o Occlusive dressing is intact to chest tube o Ostomy bag secured and not leaking o Nasal gastric tube secured o Surgical drain safeguarded • Assess condition of skin surrounding insertion site of drainage device • Assess characteristics of drainage (Type, color, amount) • Measure amount of fluid in drainage device • Discontinue and remove device as ordered • Evaluate patient’s response to drainage device and if removed how patient tolerated removal of device Oxygen Management if assigned on Kardex - Confirm oxygen delivery rate- Remember to assess and document within 20 minutes of starting the Implementation Phase

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