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General information
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 educated caregiver on Hypertensive urgency which is a situation where the blood pressure is severely elevated or higher for your diastolic pressure an that experiencing hypertensive urgency may or may not experience one or more of these symptoms: severe headache, shortness of breath, nosebleeds, and severe anxiety, chest pain, back pain, numbness/weakness, change in vision, difficulty speaking do not wait to see if your pressure comes down on its own. SN advised caregiver to seek immediately medical assistance and/or call 9-1-1 if listed above occurs or worsen with patient. Caregiver verbalized understanding of all teachings during visit.
SN instructed patient on s/s of prostate cancer. While most prostate cancer does not cause any symptoms at all, the symptoms and signs of prostate cancer may include: frequent urination, weak or interrupted urine flow or the need to strain to empty the bladder, the urge to urinate frequently at night, blood in the urine, new onset of erectile dysfunction, pain or burning during urination, which is much less common and discomfort or pain when sitting, caused by an enlarged prostate.
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.
SN instructed patient and care giver to take Carafate (sucralfate) on an empty stomach, at least 1 hour before or 2 hours after a meal and avoid taking any other medications within 2 hours before or after you take Carafate. Side effects of Carafate include: nausea, vomiting, GI upset/pain, constipation, diarrhea, insomnia, dizziness, drowsiness or headache.
SN instructed patient that the following are the common symptoms of spinal stenosis: Tingling or numbness in legs or arms, Stiffness and severe back pain, difficulty in walking and standing for long time, might experience balancing problems and resting may provide temporary relief but the symptoms reoccur.
Neuropathy assessment and teaching on management, medication, and alternative therapies to alleviate pain.