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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
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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 Δ” • 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