CVICU - Sat Probe Nursing Documentation

1
Starting 03/11/09 WY
CVICU - Sat Probe Nursing Documentation
1. Sat probe site assessment Q4H - Document
under INTERVENTIONS ACTIVITIES on flowsheet
Label SAT PROBE SITE and write WNL if
asymptomatic 2. Sat probe site change Q8H -
Document at the same place write WNL/site ?

• If you observe redness, skin irritation or
  breakdown, or discrepancies between
• O2 sat readings and visual observance of
  saturation
• Immediately change sensor and site
• Keep the sensor and give to Nursing Supervisor
• Notify the Nursing Supervisor your manager
  on-call
• Submit an Occurrence Report (Quantros)
• Document the skin assessment on flowsheet and
  careplan (skin integrity indicate pressure sore
  on R toe)
• Continue to frequently assess the wound site and
  document your assessments