No site, volume, anticoagulation status, or hemodynamic check.
The epistaxis model note in §4: the site/volume/control, the anticoagulation status, the pressure/airway management, the vital-sign watch, and the notification.
“Cannula in place.”
No nares assessment — misses a device pressure injury.
“Cannula delivering the ordered O₂; nares intact without septal/nares breakdown; padding per plan; mucosa moist.”
“Clear drainage from nose.”
After neurosurgery, this may be a CSF leak — no escalation.
“New clear watery drainage from one nostril post-transsphenoidal — neurosurgery notified urgently; HOB per order; no nose-blowing; neuro monitored.”
