Assess the nose/nares in the context of the skilled reason and document the judgment:
For epistaxis: the site (anterior/posterior), volume and duration, whether it is controlled, the anticoagulation status, and the vital-sign/hemodynamic effect of significant bleeding.
For post-nasal/sinus surgery: any packing (in place, saturation), drainage, and post-operative complication signs; for a device: the nares condition under an NG tube or cannula (pressure, breakdown) and device patency/securement.
After neurosurgery: any clear nasal drainage (a possible CSF leak) and associated signs.
MDS-supportive data
Nasal/sinus diagnoses or recent surgery are coded in MDS Section I, oxygen in Section O0110; NG feeding is coded in Section K (route to Nutrition). The record must document the nasal assessment, any packing/nares care, and bleeding surveillance so the MDS is supported.
