Wound care assessment
Diseases Process
SN instructed patient on high risk medication, anticoagulant, warfarin. Use precautions such as, Tell care
providers you take warfarin before you have any medical or dental procedures, Avoid situations that increase your risk of injury, Use safer hygiene and grooming products, Consider wearing a bracelet or carrying a card that says you take warfarin. Patient understanding.
Instructed patient drink 2 to 3 liters of liquid each day unless you were told to limit liquids because of another condition. Instructed patient when should I seek immediate care
or call 911? The nephrostomy tube comes out completely. There is blood, pus, or a bad smell coming from the place where the tube enters your skin. Urine is leaking around the tube 10 days after the tube was placed.
Instructed patient when should you contact your care
giver: you have little or no urine draining from the nephrostomy tube, you have nausea and are vomiting, the black mark on your tube has moved or is longer than when it was put in ,you have questions or concerns about your condition or care
.
SN instructed patient on importance of protecting skin by: keeping your skin moist with lotions or ointments to prevent cracking, wearing shoes that fit well and provide enough room for your feet, learning how to trim your nails to avoid harming the skin around them, wearing appropriate protective equipment when participating in work or sports.
SN instruct the patient the following symptoms could be signs of a heart attack: chest discomfort, discomfort in one or both arms, back, neck, jaw, stomach, shortness of breath, cold sweat, nausea, or dizziness. Call 911 for emergent care
if you experience any of these s / s ( symptoms / signs ).
SN instructed patient on ways to avoid acute exacerbations of chronic obstructive pulmonary disease ( COPD ) by recognizing early warning signs and then taking action to stop them in their tracks. The best way to do this is to work with your health care
provider on an action plan so you know what to do to treat an exacerbation before it becomes serious. SN instructed on early warning signs of an acute exacerbation: Wheezing or more wheezing than what’s normal for you, coughing more than usual, shortness of breath that is worse than usual, an increase in the amount of mucus, change in the color of your mucus to yellow, green, tan, or bloody, shallow or rapid breathing, more than what’s normal for you, fever, confusion or excessive sleepiness, and swelling in your feet or ankles. Patient nods head in understanding. Sn will continue to monitor.
SN explained that the problems with the veins in the legs may lead to chronic venous insufficiency ( CVI ). CVI means that there is a long-term problem with the veins not being able to pump blood back to your heart. When this happens, blood stays in the legs and causes swelling and aching. Two problems that may lead to chronic venous insufficiency are: Damaged valves. Valves keep blood flowing from the legs through the blood vessels and back to the heart. When the valves are damaged, blood does not flow as well. Deep vein thrombosis ( DVT ). Blood clots may form in the deep veins of the legs. This may cause pain, redness, and swelling in the legs. It may also block the flow of blood back to the heart. Seek immediate medical care
if you have these symptoms. A blood clot in the leg can also break off and travel to the lungs. This is called pulmonary embolism ( PE ). In the lungs, the clot can cut off the flow of blood. This may cause chest pain, trouble breathing, sweating, a fast heartbeat, coughing (may cough up blood), and fainting. It is a medical emergency and may cause death. Call 911 if you have these symptoms. Healthcare
providers call the two conditions,Deep vein thrombosis ( DVT ) and pulmonary embolism ( PE ), venous thromboembolism ( VTE ).
Tracheostomy care
Instructed patient care
giver Signs and symptoms of difficulty breathing are: Retractions Pulling of the skin between the ribs, under the breastbone or around the trach itself. Also symptoms of difficulty breathing are: Sweaty and pale skin, a person is sweaty and pale and seems to be working hard to breathe while at rest, dusky lips or nail beds. The lips or nail beds look dark, dusky or blue.
Spondylosis is a degeneration of the spinal column from any cause. The wear and tear of the spinal column is the most common cause of spondylosis. Treatment is usually conservative in nature. lifestyle modifications, chiropractic, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and osteopathic care
are help manage it.
SN to instruct patient Call your doctor or nurse call line now or seek immediate medical care
if: you have new or worse symptoms of a kidney infection. These may include: pain or burning when you urinate, a frequent need to urinate without being able to pass much urine, pain in the flank, which is just below the rib cage and above the waist on either side of the back, blood in the urine.