wound care
Others
Instructed on emergency preparedness. Planning ahead to ensure adequate care in case of severe weather or natural disaster is imperative. Here are a few key tips that warrant consideration in any elderly person’s disaster plan: Create an emergency contact card listing all of the emergency contact numbers and family information, including a list of doctors and relatives or friends who should be notified in case of injury. Discuss what to do in case of an emergency. Create a “disaster kit” that includes: Water for three days, Non-perishable food for three days (examples include protein and fruit bars, dried fruit, nuts, peanut butter, crackers, canned juices and canned food), plus a manual can opener Battery-operated radio with extra batteries, Flashlight with plenty of extra batteries Change of clothes, plus extra blankets First aid supplies, Prescription medicine list, plus copies of prescriptions Extra eyeglasses and hearing-aid batteries, Copies of medical insurance and Medicare cards, Some cash on hand, as a bank or ATM machine may be inaccessible Extra warm clothing
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.
Instructed patient What are some of the benefits of the care wear PICC line cover. The PICC line cover is antimicrobial.
It is machine washable and can be machine dried with the rest of the laundry. The PICC line cover has a unique mesh
window that allows for air to get into the dressing which is required for the dressing to be fully functional.
Instructed patient about the skin around your stoma should look like it did before surgery. The best way to protect their skin is by:
using a bag or pouch with the correct size opening, so waste does not leak, taking good care of the skin around your stoma.
Instructed patient assess bowel sounds in all 4 quadrants, assess effluent from ostomy. Empty pouch when 1/3-1/2 full, assess abdomen, report any abnormal findings immediately.
SN assessed portacath insertion site every visit. SN instructed s/sx to report to SN / MD such as redness, pain, puffiness around port, drainage from insertion site, temperature above 100 degrees, shortness of breath and chest pain. Sn instructed on portacath care and protection of the skin over the port.
Instructed patient When should I contact my healthcare provider. You drain less than 30 milliliters (2 tablespoons) in 24 hours. This may mean your drain can be removed. You suddenly stop draining fluid or think your JP drain is blocked. You have a fever higher than 101.5°F (38.6°C). You have increased pain, redness, or swelling around the drain site. If you have questions about your JP drain care contact your physician.
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 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.