UNIVERSITY HOSPITAL AND CLINICAL PROGRAMS
PROFESSIONAL NURSING ORGANIZATION
POLICY STANDARDS

ADDENDUM:        I.1a
EFFECTIVE:          4/97
REVISION:            7/08
APPROVAL:          7/08

SUBJECT: DOCUMENTATION STANDARDS

SOURCE: Policy Standards, Section I, Maintenance of Professional Practice System

1. SAFETY:

Side rails up; Bed in low position; Call light within reach; Wheels locked. ID/allergy/high risk band on.

2. IV SITE:

Observe for swelling, redness, and soreness; Dressing is clean, dry, intact

3. DRESSING:

Clean, dry, intact

4. INCISION:

Clean, dry, closure intact, edges well approximated, without inflammation or hematoma

5. DRAINS:

Patent and intact; insertion site without drainage, inflammation, or hematoma

6. ANTIEMBOLYTIC:

  1. Assess neurovascular status of lower extremities.
  2. Inspect SCD sleeves or TED's for proper fit and position on legs.
  3. Reposition every two hours and insure patency of SCD tubing.

Remove sleeves or TED's for 10 minutes and inspect skin at least every eight hours; replace immediately.

7.PACING WIRES:

 

Insertion site clean and without drainage; dressing is clean, dry, and intact; wires intact & secured to skin.  Dressing labeled with appropriate lead &/or ground wire. 

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