CPNE: IV Site assessment question...

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Specializes in Surgery, Med/Surg/ICU, OB-Peds, Ophth.

When doing assessment of the IV site, we can use the method of feeling the surrounding skin for change in temp (I prefer this over palpation) and we must also observe standard precaution & glove. My question is, has anyone had problems detecting the skin is warm?

I've not done CPNE but in real life I've never had too much of a hard time detecting if an iv is patent or not. It will be hard and usually pretty cool if its infiltrating, plus you can usually tell if the site is getting bigger. A bit harder to tell if the iv is say in the AC but a hand or wrist is pretty obvious. Hope this helps.

Specializes in Surgery, Med/Surg/ICU, OB-Peds, Ophth.

Also, am I understanding this right? Output from urinary catheters or other drainage apparatus is not measured during the PCS. In the next paragraph, output to measure may include urine, liquid stool, emesis, chest tube drainage, and/or wound/NG drainage. Why all the latter mentioned but not from a foley?

No edema noted when looking at the IV site is fine. It's easier to assess the skin if its swollen then checking for warmth. My hands are always cold.

Specializes in Tele/Neuro/Trauma.
When doing assessment of the IV site, we can use the method of feeling the surrounding skin for change in temp (I prefer this over palpation) and we must also observe standard precaution & glove. My question is, has anyone had problems detecting the skin is warm?

They prefer that you glove up and use the back of the hand over the site to check for temp. Honestly it is easier to check for edema and palpate around the site, you will definately be able to feel puffiness and swelling, except if you are lucky and your patient has an IV in the AC or the upper arm... then it's a little harder. They want you to check temp using the back of your hand.... if the IV is infiltrated, in my experience the surrounding site will be very cool bc of the fluid, which I haven't had too much trouble feeling w/a glove on. :-)

Specializes in Tele/Neuro/Trauma.
Also, am I understanding this right? Output from urinary catheters or other drainage apparatus is not measured during the PCS. In the next paragraph, output to measure may include urine, liquid stool, emesis, chest tube drainage, and/or wound/NG drainage. Why all the latter mentioned but not from a foley?

OMG this had me so flustered at first. Here is the deal with this. If it's not assigned to you on your Kardex, don't touch! Make a note of it and move on.

If they have an NGT and it's just written there as an FYI for you (ie, you are not irrigating or giving a feeding) then it is not part of your I&O. Foleys, chest tubes, etc will be ASSIGNED for you to empty or monitor or whatever the CE decides they want you to do. If it's not assigned on that Kardex under your AOC's, it's not yours. What EC told me (because I feel imcomplete without sending atleast 40 questions a week, LOL) is to just look at it to make sure there isn't something horrible going wrong with it while you are in the room, move on, document as a narrative under "other" if you choose and take it as a gift. If the bag on the foley is going to burst, I was told you may ask the CE if you can empty it. Only then, since you emptied it, do you count it as output.

If you have an IV infusing and it does not completely infuse during your implementation phase, you don't change the solution or the bag, or the IV doesn't get D/C'd, it does NOT count as intake. You make a note of the solution and the site check. Sheri recommends making a note in pencil of how much is in the bag at the start of your PCS and then if you don't need to document it as intake just erase it.

The documentation course we took really, really, really helped with all this. I just have to remember not to touch anything and pray I get out of the darn room before the trays get there!

Specializes in GI, Outpatient Surgery.
OMG this had me so flustered at first. Here is the deal with this. If it's not assigned to you on your Kardex, don't touch! Make a note of it and move on.

If they have an NGT and it's just written there as an FYI for you (ie, you are not irrigating or giving a feeding) then it is not part of your I&O. Foleys, chest tubes, etc will be ASSIGNED for you to empty or monitor or whatever the CE decides they want you to do. If it's not assigned on that Kardex under your AOC's, it's not yours. What EC told me (because I feel imcomplete without sending atleast 40 questions a week, LOL) is to just look at it to make sure there isn't something horrible going wrong with it while you are in the room, move on, document as a narrative under "other" if you choose and take it as a gift. If the bag on the foley is going to burst, I was told you may ask the CE if you can empty it. Only then, since you emptied it, do you count it as output.

If you have an IV infusing and it does not completely infuse during your implementation phase, you don't change the solution or the bag, or the IV doesn't get D/C'd, it does NOT count as intake. You make a note of the solution and the site check. Sheri recommends making a note in pencil of how much is in the bag at the start of your PCS and then if you don't need to document it as intake just erase it.

The documentation course we took really, really, really helped with all this. I just have to remember not to touch anything and pray I get out of the darn room before the trays get there!

Heres what i keep wondering.... If i do NOT get assigned skin assessment for example but pt has surgical incision, do i document the location, description etc of the incision or do not refer to it at all in my notes?? Also, for example if i am given pva- i will chart the findings but is the only place i am charting on it under the pva narrative area?

Specializes in Tele/Neuro/Trauma.
Heres what i keep wondering.... If i do NOT get assigned skin assessment for example but pt has surgical incision, do i document the location, description etc of the incision or do not refer to it at all in my notes?? Also, for example if i am given pva- i will chart the findings but is the only place i am charting on it under the pva narrative area?

It's my understanding that we are only to assess what is assigned to us and nothing more. Remember we only have such a short time for the whole thing, so I am hoping to have 20-30 mins to plan, 1 hour in the room, which leaves me 1 hour to finish up and do charting. Unless you are assigned wound management or skin assessment, or the patient is complaining about it (in which case I would then say, "let me step out t tell your primary nurse") I would leave the incision alone....

In our conference they taught us to document under our assigned AOC's narrative area, anything that didn't fall under there that we felt important to put under "other", to chart something like "primary RN ___ notified of assessment findings and measures implemented".

Specializes in Surgery, Med/Surg/ICU, OB-Peds, Ophth.
It's my understanding that we are only to assess what is assigned to us and nothing more. Remember we only have such a short time for the whole thing, so I am hoping to have 20-30 mins to plan, 1 hour in the room, which leaves me 1 hour to finish up and do charting. Unless you are assigned wound management or skin assessment, or the patient is complaining about it (in which case I would then say, "let me step out t tell your primary nurse") I would leave the incision alone....

In our conference they taught us to document under our assigned AOC's narrative area, anything that didn't fall under there that we felt important to put under "other", to chart something like "primary RN ___ notified of assessment findings and measures implemented".

"other" in the narrative notes?

Specializes in Tele/Neuro/Trauma.
"other" in the narrative notes?

Under the narratives section the last heading says "Other Observations"....

Specializes in Geriatrics, Psych.

Do you all know what this means???

KISSS-R

KEEP IT SIMPLE, SAFE, SPECIFIC- REAL

If not assigned don't do.... If the incision is not on a body part that you are assigned to do some kind of assessment to.... Don't do it!

Students have to remember that CPNE is an exam.... a CPNE student is not ... is not the Pt's Primary Nurse.... Not assigned over rides all.

EC also does not want to see a book written as narratives. If you feel you need to write an extra sentence then by all means do it.... but don't get crazy with your charting. Hope this helps

Good Luck!

Specializes in GI, Outpatient Surgery.
Do you all know what this means???

KISSS-R

KEEP IT SIMPLE, SAFE, SPECIFIC- REAL

If not assigned don't do.... If the incision is not on a body part that you are assigned to do some kind of assessment to.... Don't do it!

Students have to remember that CPNE is an exam.... a CPNE student is not ... is not the Pt's Primary Nurse.... Not assigned over rides all.

EC also does not want to see a book written as narratives. If you feel you need to write an extra sentence then by all means do it.... but don't get crazy with your charting. Hope this helps

Good Luck!

As a current LPN, it just feels wrong to NOT document it... but I know what you mean. Im so nervous I will not put something in the right place. I need to look through the paperwork we will be using again, some of it seems confusing a bit. Thank you t-lo!

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