SN used hand cleaner, donned gloves. Drainage bag from old catheter has clear yellow with sediments urine. SN donned sterile gloves, cleaned the perineum around the urinary meatus with chlorhexidine swabs. Flush Foley with 50 cc NS and immediately drained clear yellow urine. Then connected Foley to new drainage bag, then statlock placed on right thigh to secure catheter. Adult diaper put on patient. All items used for procedure disposed of in plastic bag, tied shut and put in household trash.
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.
Patient was given teaching on good body mechanics to avoid injury such as: keep your back straight as you walk and also when lifting making sure to never bend at the waist. If sitting put a pillow or rolled towel to support your lower back.
SN instructed patient on the importance of daily monitoring of the blood pressure; along with reporting an elevated BP of 160/90 and above to MD/SN stat.
SN instructed patient on low salt diet. SN instructed patient on how to read nutritional labels on commercially prepared foods. Other salt alternatives such as Mrs. Dash was encouraged. SN explained how sodium affects blood pressure and water retention.
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 reviewed patients medication with primary caregiver and instruct on medication compliance to better control the patients disease process. SN refilled patient’s medication box for daily routine implementation during visit. SN informed M.D. of patients elevated blood pressure and no new orders received, SN was advised to continue with patients current regimen.
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.
Patient instructed to advice physician if taking any herbal medicines or dietary supplements.
Instructed patient to avoid the use of electrical appliances with non-insulated wiring.