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Reviewing the Chart

- Patient Dx
- Attending Dr
- Pending orders
- Note EKG rhythm
- Labs

Patient Assessment
- Accucheck - LBM / Voiding pattern
- IV date/site/Infusion rate - Heart sounds/lung sounds
- Central Lines (type/date/# lumens, appearance)
- Pain - Pulses (Arms/Legs)
- Respiratory distress/ o2 NC (how many liters and %) - Edema (Arms/Legs)
/ IS
- Ambulation/weakness/Ambulatory aid / - Daily Weight (compare w/day before)
Hx of fall in past 12 months It is important for CHF patients
- Therapeutic VTE - Full Code/DNR
LMWH-Lovenox (enoxaparin) - Attending/Surgeon/ Team
Heparin
- Mechanical VTE (SCD’s, Compression socks)

Lines
- PICC: Inserted in arm. Ends in SVC. A central line.
- CVC: Inserted in chest or neck. Ends in heart. A central line.
- Port-a-Cath: inserted in patients that need chemotherapy, blood transfusion, ATB, IV
feedings. A central line.

Focused Assessment
- Patient with Wound Vac
 Check insertion site
 Type of suction (Continuous/Intermittent)
 Drainage (Amount/color)

- Patient with Chest Tube


 Ask for Pain
 Check insertion site and dressing (drainage, subcutaneous crepitus)
 Check amount and appearance of drainage in Pleura vac. More than 70 ml/h or
red/free flowing fluid indicates hemorrhage.
 Check if CT is dry suction or wet suction system
 Is it hooked up to wall suction (how much suction -20 h2O, -10 h20) or is it
connected to gravity.
 Teaching of IS.
- Patient post CABG
 Monitor cardiac rhythm
 Check chest (Mepitel or open to air)
 Chest tube insertion site (type of dressing or open to air)
 Pacer wires (covered or removed)
 Leg incisions used for graft. Check arm for arterial line insertion site
 Check for Edema in arms and legs
 Monitor labs (Hgb, Hct, K, Mg)
 Check peripheral pulses
 Check I/O. Report urine output of less than 30 ml/h
 Monitor VS (if HR, BP,UO-Notify MD.)
 Graft commonly used
 Left internal mammary
 Saphenous vein (inner part of leg) it is the most used

- Patient with Dx of CHF


 Check for lung sounds (crackles, dyspnea, cough, SOB.)
 Admin O2, Check O2 Sat
 Elevate HOB 30 DEGRESS
 Check for edema in lower extremities (Can elevate legs)
 Weight patient daily and compare with day before (if more than 3 pounds in 1 day or 5
pounds in 1 week notify MD)
 Check if there are orders for diuretics
 Control of I/O.
 Limit water intake and control of salt
 Check ECHO to know ejection fraction
 Put CHF protocol on file.

- Patient with Pacemaker


 Left 4x4 dressing with sling on left arm
 Do not elevate arm above shoulder level
 Pacemaker interrogation
 Check pacemaker company (ex: Metronix) for pacemaker check

- Blood transfusion
 Check Dr order for blood transfusion (verify it says TRANSFUSE)
 Check that pt signed blood transfusion consent form in chart
 Check Hgb level..
 Prime 250 ml NS bag before going to blood bank. Verify IV flushes.
 Check VS
 Verify all data with other RN. Educate pt about s/s of BT reactions.
 Take VS at beginning, after 15 min and every 30 min until.
- Preparation for Surgery
 Verify NPO orders on chart and Emar
 Verify PRBC’S units for OR are in the Emar. I can call blood bank to confirm the units
of PRBC are separated for OR.
 Patient needs to sign
 Consent for Sx
 Consent for blood transfusion
 Fill out the Sx checklist.
 Take clippers and Sx scrub to pt room. Protect IV site with nylon before patient takes
a bath.
 Get swab for MRSA and urine sample.
 Apply mupirocin (bactroban) to nares.
 First surgical bath at night, second bath at 4 am.
 Hold all medications the morning of the surgery except for a beta-blocker, if
prescribed. Give it with a sip of water. Write it on Sx checklist on chart.
 Follow the check list to remove: dentures, glasses, underwear, telepack.