pressure ulcer
General information
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 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 instructed patient / caregiver on proper incontinence care as to check every 2-3 hours if needed. Educated on pressure reduction measures as to change patient's position in bed/chair every 2-3 hours, avoid positioning on affected areas and use pressure reduction mattress or chair cushion.
SN instructed that the main job of the kidneys is to filter wastes and extra water out of your blood to make urine. Your kidneys also help control blood pressure and make hormones that your body needs to stay healthy.High blood glucose, also called blood sugar, can damage the blood vessels in your kidneys. When the blood vessels are damaged, they don’t work as well. Many people with diabetes also develop high blood pressure, which can also damage your kidneys
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 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 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.
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 instructed on arteriosclerosis is hardening and thickening of the walls of the arteries. This condition can occur because of fatty deposits on the inner lining of arteries (atherosclerosis), calcification of the wall of the arteries, or thickening of the muscular wall of the arteries from chronically elevated blood pressure. When arteriosclerosis affects the coronary arteries that supply blood to the heart muscle, a shortage of oxygen delivered to the heart itself may lead to a heart attack.
Instruct patient and caregiver regarding self-management of total knee replacement. Instructed patient about how is life different after a knee replacement it’s also normal to have temporary swelling, pressure and/or bruising in your ankles and feet, and these may last for a few months. Here are a couple things you can do to help: ice your knee (always cover ice packs in a towel to avoid frostbite, wear compression stockings, elevate your leg with a pillow, ankle exercises verbalized.