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.
SN completed patient cardiovascular and pulmonary assessment. Educated staff on monitoring patient for dizziness, syncope, cardiovascular status, anxiety, and agitation related to medication SEs. Staff to encourage patient to rise slowly to prevent syncope and dizziness. Staff instructed to monitor environmental hazards to prevent falls and injuries in addition to monitoring skin for breakdown due to episodes of bowel and bladder incontinence.
SN instructed the patient to keep oxygen away from any open flame to include smoking and also in-home pilot lights such as stove, furnace and water heater. Oxygen produced from concentrator and oxygen tanks is flammable. Call your company for a humidifier if causing nasal dryness or you may purchase lubricants made for oxygen use at your local pharmacy. Do not use Vaseline or petroleum based products as these can cause irritation and skin complications. Post no smoking / no Open Flame signs.
SN instructed the patient about care of incision site. Patient was instructed to check the incision daily for signs and symptoms of infection like increased drainage or bleeding from the incision site, redness in or around it, foul odor or pus coming from the incision, increased swelling around the area and fever above 101.0°F or shaking chills.
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 caregiver that the medical home can schedule health maintenance visits frequently enough to be proactive about new issues, ensure that the family has access to reliable information, community services, and resources and coordinate care and interpret information or advice from specialists