pressure ulcer prevention
Others
SN instructed patient and caregiver that the key difference between a suspected deep tissue injury (sDTI) and an unstageable pressure ulcer is that sDTI involves intact skin, whereas an unstageable ulcer involves a breakdown into at least the subcutaneous tissue. An unstageable ulcer is covered with necrotic tissue, such as slough or eschar, formed from remnants of the collagen matrix of subcutaneous tissue. So it’s always a full-thickness ulcer either stage III or stage IV.
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 ulcerprevention. Leaflets left in home.
Patient was instructed on the importance of a good foot care. Calluses indicate that areas of the feet are receiving too much pressure. If the increased pressure continues, the skin may break down and it is possible to get a foot ulcer.
SN instructed patient about high blood pressure. Normal blood pressure is when your blood pressure is lower than 120 / 80 mm / Hg most of the time. High blood pressure ( hypertension ) is when your blood pressure is 140 / 90 mm / Hg or above most of the time.
Patient was instructed on Why Older People Fall. There are many reasons that older people have increased risk of falling. Prevention of falls starts with identifying potentially treatable medical conditions, such as: Side effects of medications, fainting spells, vertigo.
Instructed patient in emergency care These pages will cover prevention of an emergency situation, and what to do if: Your loved one has trouble breathing or stops breathing You cannot insert a trach tube The trach falls out.
SN instructed patient and caregiver on preventing skin tears. In terms of prevention, protective arm sleeves are helpful. The use of paper or gentle release tapes is also a better alternative to nylon tape, when it comes to sensitive or aging skin. In addition, it is important to routinely moisturize dry skin with an appropriate moisturize barrier. As we age, hydrating dry skin helps to replenish missing skin and keep skin healthy and intact. Oral hydration is important as well. Patient and caregiver verbalize understanding instructions given.
Sn instructed that reducing sodium intake lowers blood pressure and prevent the collection of fluid in the lower legs or abdomen. People with chronic kidney disease must control sodium intake to prevent volume overload, which increases blood pressure and causes swelling. Food to eat any fresh or frozen beef, lamb, pork, poultry and fish. Eggs and egg substitutes. Low-sodium peanut butter. Dry peas and beans (not canned) drained, water or oil packed canned fish or poultry foods to avoid canned food canned vegetables processed meats salted snacks such as, salted peanuts, salted almonds etc.
Patient was instructed on symptoms of leg edema. If having leg edema feet and legs will initially appear swollen as the day progresses. After a period of time, however, the swelling will set in first thing in the morning and worsen throughout the day. Over time other symptoms will develop: High blood pressure, headaches, increased urination, palpitations, swollen hands and/or wrists, puffy eyes, weight gain.
Patient was instructed on relieving and preventing leg edema. The first line of defense is: leg elevation. Elevate legs above the level of the heart which puts minimal pressure on the back of the knees and thighs and lower back. Other help to decrease swelling is limiting salt intake, drink plenty of water, avoid sitting with the feet dependent. Do not abuse diuretics and laxatives.