Patient recently discharge from acute hospital s/p intracranial hemorrhage and SN educated patient on s/s such as Weakness., Tingling, weakness, or paralysis (loss of movement) on one side of the body. Difficulty speaking, disorientation and confusion, loss of or change in vision, difficulty swallowing, change in level of consciousness (alertness) and advised patient and caregiver to contact medical professional if any noted.
Discharge planning initiated on today's visit. Reviewed with patient /PCG s/s of disease exacerbation that need to be reported to health care providers including steps on what to do in an event of an emergency. Medication pill box set up checked and emphasized the importance of timely refill of medications to prevent missing or skipping doses, pain management, continue following prescribed diet regimen. Re-instructed on infection control measures and practicing standard precautions, most importantly, frequent proper hand washing to prevent disease complications.
Patient and caregiver taught on discharge planning, to follow up with PCP with any new changes, to continue with care as instructed and/or taught by nurse.
Instructed in D/C planning. Instructed to keep MD appointments, take medication exactly as MD ordered and report any S/E and/or S/S to avoid further complications.
