Wound care assessment
Instructed in woundcare per MD order using aseptics technique.
SN instructed patient on woundcare. The patient should be sure to have a well-balanced diet. This include protein, vitamins and iron. Note: using a blender or
chopping food does not change the nutritional value of the food.
SN instructed pt on hygiene r/t woundcare. It is very important to maintain a clean environment as well as clean , dry skin. Do not pick at wounds, or at other areas of the skin. Our fingernails harbor bacteria under them, wash hands throughly and often throughout the the day with soap and water, hand sanitizer can be used in between but are not a substitute for proper hand washing.
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 patient cardiovascular and pulmonary assessment. Medication reviewed and administered. Educated staff on monitoring patient for mood changes, aggressive episodes, anxiety, and agitation related to medication SEs. Staff instructed to monitor environmental hazards to prevent falls and injuries. Staff was also encourages to encourage patient to rise slowly to prevent syncope and dizziness.
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.