patient-unable
General information
Instructed patient to avoid candies, chocolates, cookies, drinks and others foods rich in sugar. Patient was instructed on the importance of a good nutrition to control hyperglycemia: Avoid skipping meals. This can make people extra hungry, moody and unable to focus. Pay attention to the portion. Eat healthy.
SN instructed patient / caregiver on service authorization, advance directives, rights and responsibilities, rights of the elderly and obtained necessary signatures. Instructed patient / caregiver on 24 hour nurse availability and provided / posted the agency telephone number. Also instructed that after hours, weekends and holidays an answering service will reach the nurse and he / she will return the patient / caregiver call and answer any questions or make a visit if needed. Patient and caregiver stated understanding. Patient and caregiver educated on diabetic diet, diabetic foot care, symptoms / signs ( s / s ) of depression, managing pain with medications, healthy skin, and pressure ulcer prevention. Leaflets left in home.
SN assessed patient 's home for adverse extreme temperatures. Today the patient home is adequately heated. Patient was instructed to call their city's local warming center as needed. Patient verbalized understanding.
SN completed assessment done on all body systems and noted patient with elevated blood pressure during visit. SN completed treatment during visit and noted no drainage on old tx, wound callused and new area found to left medial top of foot remains intact with no drainage noted. SN noted patient complaint of pain to bilateral lower extremities with +2 edema noted. SN educated primary caregiver on the importance of elevation of bilateral lower extremities as well as pain management for patient.
Skilled nurse developed patient plan of care with patient/caregiver involvement to be countersigned by physician. SN to perform complete physical assessment each visit with emphasis on disease process. SN to assess other co-morbidities including list diseases and other conditions that present themselves during this episode of care. SN to recognize and intervene to minimize complications; notify physician immediately of any potential problems that impede completion of patient recovery and desired goals.
SN completed patient cardiovascular and pulmonary assessment. Medication reviewed and administered. Educated staff on monitoring patient for mood changes, aggressive episodes, anxiety, and agitation related to medication SEs. Staff instructed to monitor environmental hazards to prevent falls and injuries. Staff was also encourages to encourage patient to rise slowly to prevent syncope and dizziness.
SN completed patient cardiovascular and pulmonary assessment. Educated staff on monitoring patient for dizziness, syncope, cardiovascular status, anxiety, and agitation related to medication SEs. Staff to encourage patient to rise slowly to prevent syncope and dizziness. Staff instructed to monitor environmental hazards to prevent falls and injuries in addition to monitoring skin for breakdown due to episodes of bowel and bladder incontinence.
SN instructed patient on low salt diet. SN instructed patient on how to read nutritional labels on commercially prepared foods. Other salt alternatives such as Mrs. Dash was encouraged. SN explained how sodium affects blood pressure and water retention.
SN instructed the patient about care of incision site. Patient was instructed to check the incision daily for signs and symptoms of infection like increased drainage or bleeding from the incision site, redness in or around it, foul odor or pus coming from the incision, increased swelling around the area and fever above 101.0°F or shaking chills.
SN instructed patient/ CG about thickened liquids. SN explained that thickened liquids are used to treat patients with Dysphagia. Thick liquids decrease aspiration. Thick liquids may give the patient more time to perform additional swallows or other swallowing strategies. Thickened liquids slow down the bolus flow to compensate for a delayed swallow and reduced airway closure.