Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 10-6

Caring for a Patient Receiving Continuous Wound

Perfusion Pain Management

Goal:The patient reports increased comfort and/or decreased

pain, without adverse effects. Comments

1. Check the medication order against the original medical
   order, according to agency policy. Clarify any inconsisten-
   cies. Check the patient’s chart for allergies.


2. Know the actions, special nursing considerations, safe dose
   ranges, purpose of administration, and adverse effects of
   the medications to be administered. Consider the appropri-
   ateness of the medication for this patient.


3. Perform hand hygiene and put on PPE, if indicated.


4. Identify the patient.


5. Close the door to the room or pull the bedside curtain.


6. Assess the patient’s pain. Administer postoperative
   analgesic, as ordered.


7. Check the medication label attached to the balloon. Com-
   pare with the medical order and MAR, per facility policy.
   Assess the patient for perioral numbness or tingling, numb-
   ness or tingling of fingers or toes, blurred vision, ringing in
   the ears, metallic taste in the mouth, confusion, seizures,
   drowsiness, nausea and/or vomiting. Assess the patient’s
   vital signs.


8. Put on gloves. Assess the wound perfusion system. Inspect
   tubing for kinks; check that the white tubing clamps are
   open. If tubing appears crimped, massage area on tubing
   to facilitate flow. Check filter in tubing, which should be
   unrestricted and free from tape.


9. Check the flow restrictor to ensure it is in contact with the
   patient’s skin. Tape in place, as necessary.


10. Check the insertion site dressing. Ensure that it is intact.
    Assess for leakage and dislodgement. Assess for redness,
    warmth, swelling, pain at site, and drainage.


11. Review the device with the patient. Review the function of
    the device and reason for use. Reinforce the purpose and
    action of the medication to the patient.

ExcellentSatisfactoryNeeds Practice