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 provided teaching regarding hypokalemia. Low potassium (hypokalemia) refers to a lower than normal potassium level in your bloodstream. Potassium helps carry electrical signals to cells in your body. It is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells. S/s include weakness, muscle cramps, heart palpitations, and constipation. SN instructed that patient should report any of these to her nurse promptly. Verbal understanding noted.
Monitor circulation r/t compression dressing. Report if dressing is tight and constricting esp. in back of leg. Check color of feet and report if bluish or purple in color. Report any c/o numbness or tingling. Dressing should be removed immediately if any s/s occur. and notify doctor or nurse.
SN instructed about aspiration precautions. Consume honey thick liquids. Do not use a straw to drink fluid. Sit straight up when eating or drinking, have supervision with meals, do not eat alone. Sit up at least 1/2 hour after a meal.
SN instructed patient and caregiver on how to stop a nosebleed. Make a thumbs up with hand on same side as nose bleed. Press side of nose that is bleeding closed and tilt head slightly down to prevent blood from going down into throat. Stay still for 5-10 minutes then gently release. Refrain from blowing nose or putting a tissue in nose x 24 hours. If bleeding does not stop seek medical attention.
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.
Instructed patient what are the risks of having a Jackson-Pratt drain. The JP drain site may be painful. You may have trouble lying on the side with your JP drain. Your JP drain site may leak. The JP drain may be pulled out by accident. The tubing may get blocked, crack, or break. The tubing may damage your tissue. You may have a scar. The JP drain site may get infected. This infection could spread inside your body.
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 to get a flu shot each year and decrease the exposure to the flu. Avoiding the flu is especially important for people who have or are at risk for heart disease. This highly contagious infection causes symptoms similar to the common cold, only more severe, other symptoms include debilitating muscle or body aches, vomiting and diarrhea, and fever. Having a serious infection puts extra stress on your heart, which increases your heart's need for oxygen. Coughing and congestion can make breathing more difficult. As a result, your heart may not get sufficient oxygen. Patient verbalized understanding.
Patient was educated on how to wear ordered arm sling, Gently pull the sling over your arm and elbow. It should fit snugly around the elbow, reach around your neck and grab the strap behind your elbow and tighten the straps so your hand and forearm are elevated above the level of your elbow. Orders were to maintain sling at 90 degree angle and to avoid any activities with the arm. Patient verbalized understanding