patient-unable
General information
Patient was instructed on appropriate nutrition. Eat healthy, eat more fiber, try whole grains fresh fruits, and raw vegetables. Try picking from the rainbow of colors to maximize variety. Eat non starchy vegetables such as spinach, carrots, broccoli or green beans with the meals.
Instructed patient about foods high in cholesterol, such as, organ meats, read meats, fatty poultry, shrimp, bacon, cold cuts, hot dogs, saturated fats (found in animal fats and coconut oil), palm kernel, cocoa butter, hydrogenated fats, chocolate, margarine, nondairy substitutes, whole milk, egg yolks, fried foods, and others.
Instructed patient about methods for adjusting the diet to meet a change in activity greater caloric intake is required for prolonged or strenuous activity to prevent hypoglycemia.
Patient was given teaching on good body mechanics to avoid injury such as: keep your back straight as you walk and also when lifting making sure to never bend at the waist. If sitting put a pillow or rolled towel to support your lower back.
SN instructed patient on the importance of daily monitoring of the blood pressure; along with reporting an elevated BP of 160/90 and above to MD/SN stat.
SN reviewed patients medication with primary caregiver and instruct on medication compliance to better control the patients disease process. SN refilled patient’s medication box for daily routine implementation during visit. SN informed M.D. of patients elevated blood pressure and no new orders received, SN was advised to continue with patients current regimen.
SN educated caregiver on Hypertensive urgency which is a situation where the blood pressure is severely elevated or higher for your diastolic pressure an that experiencing hypertensive urgency may or may not experience one or more of these symptoms: severe headache, shortness of breath, nosebleeds, and severe anxiety, chest pain, back pain, numbness/weakness, change in vision, difficulty speaking do not wait to see if your pressure comes down on its own. SN advised caregiver to seek immediately medical assistance and/or call 9-1-1 if listed above occurs or worsen with patient. Caregiver verbalized understanding of all teachings during visit.
SN used hand cleaner, donned gloves. Drainage bag from old catheter has clear yellow with sediments urine. SN donned sterile gloves, cleaned the perineum around the urinary meatus with chlorhexidine swabs. Flush Foley with 50 cc NS and immediately drained clear yellow urine. Then connected Foley to new drainage bag, then statlock placed on right thigh to secure catheter. Adult diaper put on patient. All items used for procedure disposed of in plastic bag, tied shut and put in household trash.
SN instructed patient and care giver to take Carafate (sucralfate) on an empty stomach, at least 1 hour before or 2 hours after a meal and avoid taking any other medications within 2 hours before or after you take Carafate. Side effects of Carafate include: nausea, vomiting, GI upset/pain, constipation, diarrhea, insomnia, dizziness, drowsiness or headache.
SN instructed patient on importance of hand washing before and after eating, after using the bathroom , after blowing your nose, coughing, or sneezing, after being outside , in order to prevent spread of germs.