assessment
Instructed in the assessment of their chest pain, including amount, frequency, location, duration and any associated symptoms. Instructed to report these to the health care professional.
Instructed patient about the assessment of chest pain, including amount, frequency, location, duration and any associated symptoms. Also instructed patient to report immediately to his/her doctor.
Instructed patient that when on your assessment findings (coarse breath sounds, noisy breathing, and prolonged expiratory sounds) indicate that your airway needs clearing, suction it using sterile technique. Hyperoxygenate him before and after suctioning and between passes to compensate for suctioning-induced hypoxemia.
SN assessment done on all body systems. Checked blood sugar daily monitoring on patient's log book, hydration, dietary, and medication compliance. Instructed patient on keeping blood glucose within normal range and preventing the development of long-term complication. Careful monitoring of diet, exercise and blood sugar levels are as important as the use of oral medications in preventing complications of diabetes. Also taught infection control, safety/fall precautions and preventions, and to contact MD for any emergency and/or medical concerns and changes.
SN complete assessment done on all body systems, checked vital signs, blood sugar monitoring, hydration, nutrition intake, and medication compliance. SN refilled patient’s medication box for daily routine. Taught patient to carefully manage her blood sugar with diet, physical activity, and medication to prevent diabetes complication and avoid hypo/hyperglycemia.
Patient assessment done with special attention on neuro-musculoskeletal and general status. Vital signs monitored.
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 instructed patient about tracheotomy care suctioning always involves: assessment , oxygenation management, use of correct suction pressure, liquefying secretions, using the proper-size , suction catheter and insertion distance appropriate patient positioning, evaluation, using the proper - size suction catheter and insertion distance appropriate patient positioning evaluation.
Physical assessment done to patient after chemotherapy . Medication checked and reconciled. Hydration and nutritional status checked. Diet reviewed. Denies chest pain. Tube care done per physician ( MD ) order. Dressing changed. Still complained in pain in fingers, patient taught that one side effect of chemotherapy is pain in fingers which is called peripheral neuropathy, it results from some type of damage to the peripheral nerves. Certain chemotherapy drugs can cause peripheral neuropathy such as Vinca alkaloids ( vincristine ), cisplatin, Paclitaxel, and the podophyllotoxins ( etoposide and tenoposide) . Other drugs used to treat cancer such as thalidomide and interferon also can cause peripheral neuropathy.
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.