Skills Performed

Foley catheter changed per sterile technique – ___ cc balloon deflated with syringe and foley catheter withdrawn. Catheter intact and removed without complication. Gloves removed and hands cleansed with hand sanitizer. Site cleansed with 3 swabsticks of PVP solution. ___ FR ___ CC foley catheter lubricated with water soluble lubricant and catheter inserted. ___ cc urine noted and balloon inflated to ___ CC. Catheter connected to drainage bag and secured with leg strap. Patient tolerated procedure well.

IV therapy done per aseptic technique. IV site flushed with ___ cc normal saline, IV MEDICATION OF ________ INFUSED AT ___ CC/HR OR PUSHED OVER ___ MINUTES. Following infusion, IV flushed with ___ cc normal saline, followed by ___ cc heparin. Patient tolerated procedure well.

Pt. had blood drawn per aseptic technique from ___ for the following blood tests: _____. Tourniquet applied to upper arm, site wiped with alcohol, and sample obtained and transferred to _____ top tube. No bruising noted and patient tolerated procedure well. Samples delivered to Del Sol Hospital with this agencies fax number (702) ______ on requisition sheet and instructions to fax to agency asap.

PICC line dressing change done per sterile technique to ___ arm. Mask and non-sterile gloves donned and patient instructed to turn head to the side away from PICC line site to avoid contamination. Alcohol prep pad rubbed over tape and dressing to allow easy removal. Old PICC line dressing removed and discarded and site inspected for erythema, drainage, and torn skin – none noted. Non-sterile gloves discarded and hands cleansed with antiseptic gel. Sterile gloves applied and chloraprep used to swab entire PICC line site working from the insertion site outward.  Bio-patch applied at insertion site and PICC line secured with STAT-LOCK. Tegaderm applied over entire site and dressing dated. Both end caps changed and sites flushed with __ cc NS and __ cc Heparin. Patient tolerated procedure well.

Port-a-cath flush per sterile technique. Site cleansed with betadine followed by alcohol swabs.  Access needle and extension tubing primed with NS and clamped. Using a 90 degree angle, port-a-cath accessed and approximately 3 cc blood obtained and discarded. 10 CC NS infused into port-a-cath followed by 5 cc heparin. Huber needle removed. Patient tolerated procedure well.

PT/INR test done per aseptic technique to ___ finger. Results:

PT:

INR:

QC1:

QC2:

Results called into ____ MD. New orders are to take ___ mg of coumadin QD / QOD and re-check in __ week. Pt. instructed on dose of coumadin to take, as well as next PT/INR test. Pt verbalized100% understanding.

REGULAR wound care & ORTHO 7 day wound care note:

Wound care done per aseptic technique to wound care site. Old dressing removed and site cleansed with __, patted dry, applied __, covered with __, wrapped with __ and secured with tape.

Wound size is __ x __ x __ cm

tunneling of __ cm @ __ o”clock

undermining of __ cm @ __ o’clock to __ o’clock

Drainage is: sanguineous (red), serosanguineous (pink and watery), serous (thin and watery), purulent (tan/yellow)

Wound bed is __ % granulation tissue, __ % epithelialization, __ % slough, __% eschar

Surrounding area of wound is clean, dry and intact – red – hard

Odor is present / not present.


Wound care done per aseptic technique to wound care site of right knee. Old dressing removed and site cleansed with wound cleanser and patted dry, staples in place and incision is approximated with no dehiscence noted. Painted site with betadine, covered with dry sterile dressing, and secured with tape. Wound size is __ x __ x __ cm. NO tunneling or undermining noted Drainage is: serosanguineous (pink and watery), Surrounding area of wound is clean, dry and intact with slight inflammation present. Odor is not present.

Old vac dressing removed and discarded, no particles of foam noted in wound bed. Peri-wound area is free from redness, maceration or callous. Wound bed is pink / red / grey / with / with no / undermining / and / or tunneling noted. Measurements as noted. With new gloves applied and using aseptic technique, wound cleansed with normal saline and VAC drape applied to peri-wound area. GranuFoam dressing cut to fit wound, ensuring that all parts of wound were in contact with foam. Second layer of VAC drape applied to wound leaving a 2cm border, and a “quarter-sized” hole cut in VAC drape. VAC TRAC pad applied over opening in drape, TRAC pad tubing connected to canister tubing, and wound VAC commenced at 125mmHg, continuous suction. No air leak or wound vac malfunction noted at this time. Cannister is noted to have ___ml of serous / serosanguinous / bloody / purulent / yellow / green drainage and changed at this time. / due to be changed on _______.

Wound size is __ x __ x __ cm.

tunneling of __ cm @ __ o”clock.

undermining of __ cm @ __ o’clock to __ o’clock.

Wound bed is __ % granulation tissue, __ % epithelialization, __ % slough, __% eschar.

Surrounding area of wound is clean, dry and intact – red – hard.

Odor is present / not present.

TEACHINGS

Teaching on Alzheimers disease – Communication skills

It was explained to the patient/caregiver that although communication problems will arise it is very important that the patient is spoken to as an adult, treated with respect, and praised for doing well. It is very important to maintain the adult relationship with the patient. Some examples to help communicate better: donít assume patient has problems because the Alzheimerís is getting worse, use a soft gentle tone, donít smother patient, encourage patient to talk to other people, use simple humor, compliment patient often, show patient that you care, keep talking to patient even if he/she can no longer talk. Use facial expressions, gestures or cues, limit noise and distractions, repeat yourself more than once, ask questions that require a ìyesî or ìnoî – (limit using open-ended questions), and allow the patient time to answer (donít rush him/her).
Above all else be patient when communicating. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Definition and Risk factors

SN defined Alzheimerís to the patient and caregiver as one form of dementia that affects an individualís ability to remember, reason, and communicate. Patient and caregiver explained some of the risk factors of Alzheimerís as follows: aging, changes in nerve endings and brain cells, chemical changes in the brain, viruses, genetic, things in the environment, head trauma, Downís syndrome, and diseases that damage blood vessels, such as, high blood pressure, heart disease, stroke and diabetes. SN discussed the care team phone numbers and its helpfulness with the patient and caregiver. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Depression

SN defined Alzheimerís to the patient and caregiver as one form of dementia that affects an individualís ability to remember, reason, and communicate. Patient and caregiver explained some of the risk factors of Alzheimerís as follows: aging, changes in nerve endings and brain cells, chemical changes in the brain, viruses, genetic, things in the environment, head trauma, Downís syndrome, and diseases that damage blood vessels, such as, high blood pressure, heart disease, stroke and diabetes. SN discussed the care team phone numbers and its helpfulness with the patient and caregiver. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Diet and food issues

SN discussed the possible food issues the patient could face related to Alzheimerís. The importance of choosing foods the patient likes, finger foods, allowing for snacking, and drinking plenty of fluids was discussed. It was explained that during the early stages of the disease the patient most likely will be able to feed themselves with little to no help, however, in the later stages he/she may need help with chewing, swallowing, and keeping the food on his plate. During these later stages you may find that he/she pockets the food, may need lots of reassurance, and firm prompting to eat. It was discussed with the caregiver that during these times they should be calm, cheerful, and serve foods he/she likes as much as possible. If as the caregiver, you find it difficult to manage feeding times make arrangements for someone who has a great deal of patience to help you. It was further discussed with the patient and caregiver that they: make meal and snack times the same time daily, make sure the he/she is in an upright position when eating, sit in front of him/her while eating to avoid distractions, put out only the necessary utensils, use bowls instead of plates, tie a towel around his/her neck to avoid dirty clothes, use drink cups with spill proof lids, serve one food at a time, allow plenty of time to eat, check the temperature of foods prior to serving, make the food easy
to eat, only serve foods that are soft and easy to swallow, serve finger foods, and serve small amounts of food to avoid choking. Patient and caregiver verbalized understanding and voiced no concerns.

 

Teaching on Alzheimers disease – Exercise

SN discussed with the patient and caregiver the importance of incorporating exercise into the patientís daily routine. It was explained that exercise is a good way for the patient to relieve tension, worries, restlessness, wandering, help with appetite, and sleep. The regular exercise will allow the patient to keep from losing strength. Patient and caregiver reminded that it is important to incorporate periods of rest during the exercise sessions and to check with the doctor before starting an exercise program. SN explained the following as some ideas for exercise for the patient: walk, climb stairs, housework or yard work. Patient and caregiver verbalized understanding and voiced no concerns.

 

Teaching on Alzheimers disease – Medication

SN discussed with patient and caregiver that there is no cure for Alzheimerís but there are drugs that can be used to treat it. SN explained that the current drugs available cannot reverse the loss of brain cells, but they may help to reduce the symptoms. Aricept/Exelon/Razadyne is currently being used to treat mild to moderate Alzheimerís. These medications are started at a low dose and increased over time to manage any side effects such as: headache, nausea, vomiting, loss of appetite, and diarrhea.
Currently, there is one medication being used to treat moderate to severe Alzheimerís and it is Namenda. It was explained to the patient that while taking this medication it is very important that they do not drink alcohol or use tobacco products as it will change the effectiveness of the medication. The side effects of the medication were explained as headache, constipation, confusion, and dizziness. Patient and caregiver were advised to never change the dose or stop taking the medication without the direction of a doctor. SN discussed with patient and caregiver that Vitamin E supplements are prescribed to help the brain cells defend against free radicals, a kind of oxygen that can damage the brain cells. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Mood Changes

SN discussed with the patient/caregiver the mood/behavior changes the patient will experience as the disease progresses. Some examples to help prepare and
limit frustration during these times are: pay attention, keep his/her surroundings pleasant and simple, make patient feel safe, incorporate rest periods,
don’t argue with patient, don’t confuse patient with too many questions or choices, if patient is active or restless have them sit in a swivel chair, limit
the amount of noise and light, and check on patients personal comfort often.
Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

Teaching on Alzheimers disease – Memory retention

SN discussed that as the disease progress the patient may forget more important matters and need help to refresh his/her memory. Patient/Caregiver given
examples to help refresh the memory:
keep things familiar and routine, put large calendar and clock in the room, place notes around the house, put name tags on household items, review family
members’ names and talk about past events, talk about things he/she likes, remind him/her about trips or appointments no more than one day in advance,
control wandering by locking the doors, use a night light in the bathrooms and hallways, and be patient.

Some other things that can be done to assist with memory are to use certain smells or music to recall a memory. These are things that can be used at later times to help soothe the patient. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Safe environment INSIDE the home

Patient instructed on maintaining a safe environment in the home for patients with Alzheimer’s. SN instructed patient on safe floor coverings such as short-pile carpet, indoor/outdoor carpet, and non-skid surfaces. Maintaining a pathway clear of toys, shoes, throw rugs, and other objects was discussed with the patient. Patient instructed to secure electrical cords away from the walking path. SN discussed adding night lights to the bathroom, bedroom, and hallways with the patient to maintain good lighting to prevent accidents. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Safety environment OUTSIDE the home

Patient instructed on safety outside the home. SN discussed with patient when walking or exercising outside to do so in a familiar and safe area. Patient
advised that if they are unfamiliar with the area or surrounding to go into a store or office building and ask for directions. Be alert when outside the
home distractions such as earphones that can inhibit your ability to hear traffic, animals, and etc. SN discussed with patient carrying a cell phone when outside the home and not carrying things that may tempt a thief. Discussed with the patient always carrying valid identification, emergency numbers, and letting someone know where they are going. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Signs and Symptoms

SN discussed with patient and caregiver the signs and symptoms of early/progressive Alzheimer’s as follows:

EARLY SIGNS AND SYMPTOMS – decreased focus, memory, judgement or a reduction in the ability to express thoughts,feelings, or perform complex tasks. Other
symptoms include the patient becoming increasingly restless, depressed, or changes in sleep/wake patterns and mood swings.

PROGRESSIVE – Symptoms progressively worsen from the early stages and there may be an increased dIfficulty in writing, eating, being around people, traveling
alone, memory, concentration, orientation, walking, judgment, words, daily tasks, maintaining interest in activities, bowel and bladder functions, and
controlling behavior. Symptoms may also include an increase in restlessness and mood swings.SN instructed patient and caregiver that these symptoms vary per
individual and progress at various intervals per person. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

Patient and caregiver instructed on tips to have patients with alzheimer’s disease maintain their own personal care such as: keeping a regular routine,
laying out everything the he/she will need during bathing, give reminders of where and how to wash if it is needed, keeping the closet simple, choose
clothing that is easy to put on and take off, set up a routine for grooming, and make a list of grooming tasks and tape it to the bathroom mirror.Patient and
caregiver verbalized understanding of instructions given and voiced no concerns.

 

Teaching on Alzheimers disease – Sundowners syndrome

SN discussed that as the disease progresses the patient may begin having symptoms of sundowning. This was explained to the patient/caregiver as an increase
in agitation/anger, confusion and delirium, as the day turns into night. If the patient begins to experience signs of sundowning the following are some tips to help:

plan things in the morning rather than afternoon, keep him/her awake during the day, increase lighting in the home, restrict caffeine use to mornings if possible, and physical activity/exercise may help him use up more energy.
Patient and caregiver verbalized understanding of instructions given and voiced no concerns

 

Teaching on Alzheimers disease – Wandering

SN discussed the possibility of patient wandering. Reasons: boredom, short-term memory problems, need for activity, new surroundings, looking for the past,
confused about the time, and coping with pain.

CG instructed to decrease/stop wandering the root cause must be identified. Once identified the following solutions can be used: provide visual cues (signs around the home as to where they are), Plan activities and distractions, provide a place to wander safely (such as in the backyard or through rooms in the house), place STOP signs on doors to provide cue to patient to not open door.

If wanderings persist, CG will need to observe patient more closely, inform neighbors of patient wanderings and have them alert CG, install door alarms/locks or have patient wear GPS device such as Keruve (www.keruve.com) (917) 310-0973
Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

Teaching on Arthritis – Comfort Tips

Comfort tips were discussed with the patient as: prepare to go outdoors by dressing for the weather, take medications early, find quite time, bed comfort, clothing, and the use of hot and cold packs. SN discussed for those individuals that spend a fair amount of time in bed position changes will help: exercise the joints, breathe better, improve blood flow, prevent pressure ulcers, feel better, avoid harm to joints and muscles, and improve range of motion.

Teaching on Arthritis – Definition and Types

SN defined Arthritis to the patient and caregiver as an inflammation in the body’s joints. Arthritis most affects the joints in your hands, knees, feet, or hips. It can affect supportive tissue and other parts of the body as well. The SN explained that there are many forms of Arthritis to include the following: ankylosing spondylitis, rheumatoid arthritis, gout, psoriatic arthritis, juvenile arthritis, and infectious arthritis.

Teaching on Arthritis – Diet

SN discussed with the patient and caregiver the importance of diet and provided the following examples that can help arthritis: calcium and magnesium can help the bones become and stay strong. Examples include: herring salmon, sardines (if eaten with the bones). Also tofu, green leafy vegetables, oats, parsley, figs, prunes, sesame seeds, oranges, milk, meats, seafood, avocados, bananas, brown rice, apples, apricots, and garlic are known to help with arthritis.. It was explained that there are foods to avoid that could exacerbate arthritis symptoms such as: alcohol, fat- fast food, cheese, butter, bacon, cream, whole milk, ham, and hotdogs.

SN further discussed with the patient and caregiver the importance of maintaining a healthy weight. It was explained that more weight forces the bones and joints to work harder to support the body, resulting in inflammation of arthritis symptoms

Teaching on Arthritis – Exercise Program

SN discussed with the patient and caregiver the importance of maintaining an exercise program to help maintain flexibility to the joints and maintain strength to the muscles. The following are some examples of exercise that can be done: flexibility exercises- putting your joints through their full range of motion, strength exercises-push body parts against some kind of force, endurance- helps to work your heart and lungs better, and pool exercises help to support the body and relieve joint pain.

Teaching on Arthritis – Medication Treatment Types

SN explained to the pt/CG that there are various medications that are currently being used to treat the various types of arthritis. Medications include:

Anitmalarial Used to treat rheumatoid arthritis. May cause damage to the eye so regular eye exams should be performed.

Aspirin- Helps to reduce the pain and inflammation. May cause minor stomach problems so do not take on an empty stomach,

Corticosteroids- Used to treat severe cases of arthritis which is used like a natural form of cortisone that is found in the body,

COX-2 inhibitors- Uto treat rheumatoid arthritis and osteoarthritis. Low risk of side effects with the class of medication.

Gold treatments- Is used to treat rheumatoid arthritis when other treatments fail. It is unknown how these treatments help some patients. During these treatments blood and urine test will be monitored as well as the following side effects: skin rashes, metal taste, sores in the mouth, dizziness, fainting, nausea or vomiting.

Penicillamine- Used when no other treatments have worked. May suppress symptoms such as pain, tenderness, swelling. May take a few months to take effect and should not be taken in conjunction with gold treatments,

Immunosuppressive drugs- Used to fight an infection causing damage to the bones and tissue. It also inhibits the body’s ability to fight infection so blood tests will need to be monitored,

NSAIDs- Used to relive joint pain and should not be taken on an empty stomach,

Supplements- Can help keep the joints limber and ease pain, B vitamins, folic acid, B12, Niacin, Vit. C, Vit. D, Vit. E, Boron, Calcium, Glucosamine sulfate, and MSM.

Teaching on Arthritis – Mobility Types

Patient and caregiver educated regarding the mobility aids and assistive devices for those individuals living with arthritis, such as: walker, wheelchair, crutches, cane, dressing stick, grabber, shoe horn, raised toilet seat, bath stool, sock donner, and elastic or Velcro shoelaces.

Teaching on Arthritis – Risk Factors

SN insgtructed pt/CG that certain factors have been shown to be associated with a greater risk of arthritis. Some of these risk factors are modifiable while others are not.

Non-modifiable risk factors
Age: The risk of developing most types of arthritis increases with age.
Gender: Most types of arthritis are more common in women; 60% of all people with arthritis are women. Gout is more common in men.
Genetic: Specific genes are associated with a higher risk of certain types of arthritis, such as rheumatoid arthritis (RA), systemic lupus erythematous (SLE), and ankylosing spondylitis.

Modifiable risk factors
Overweight and Obesity: Excess weight can contribute to both the onset and progression of knee osteoarthritis.
Joint Injuries: Damage to a joint can contribute to the development of osteoarthritis in that joint.
Infection: Many microbial agents can infect joints and potentially cause the development of various forms of arthritis.
Occupation: Certain occupations involving repetitive knee bending and squatting are associated with osteoarthritis of the knee.

Teaching on CHF – Cardiac Demand Reduction

SN discussed the following ways to avoid unnecessary demands on the heart: control high blood pressure, lose weight, control diabetes, stop smoking as it causes vasoconstriction and makes breathing more difficult, reduce emotional stress, avoid extreme temperatures, maintain cholesterol levels, stay away from sick people, avoid tight binding clothes, and only drink alcohol with doctor permission. SN spoke to the caregiver and discussed taking care of them self and asking for help.

Teaching on CHF – Daily Weights

SN instructed pt/CG on daily weight self-monitoring program where the patient utilizes the same scales on a hard, flat surface each morning prior to breakfast and after urination. Report to SN weight of > 2 lbs in 1 day or 5 lbs in 1 week

Teaching on CHF – Definition

SN defined heart failure to the patient/caregiver is when the blood that should be pumped out of the heart backs up in the lungs and other parts of the body causing shortness of breath or swelling in the abdomen, hands, legs, and feet. Many people with heart failure have an enlarged heart which comes from years of the heart having to struggle to pump out the blood.

Teaching on CHF – Diet and Fluid restriction

SN discussed with the patient/caregiver the importance of maintaining a healthy weight as well as dietary restrictions. It was explained that eating foods high in potassium can help to replace what is being lost when taking a diuretic. The following examples were given: raisins, dried prunes, strawberries, bananas, avocados, white potatoes, broccoli, tomatoes, mushrooms, dried beans, peas, turkey, fish, and beef. Patient was reminded that sometimes food alone cannot replace the potassium lost and supplement will need to be taken. It was discussed the importance of eating foods low in sodium to reduce the edema in the body. SN explained that it is important not to replace the fluid that is being removed by the diuretic therefore it is important to limit the amount of fluids being consumed. SN suggested using sugar free hard candies to help with a dry mouth. It was further explained that the doctor will determine how fluid should be consumed daily and as a reminder water taken with medications does count towards the daily fluid restrictions

Teaching on CHF – Dyspnea

SN instructed on Dyspnea, or difficulty breathing, with pt/CG and the following tips were given to increase comfort of breathing: keep items used often close at hand, when sitting/lying down make sure all parts of the body are supported to help relax, sit upright or propped up on pillows, prop your arms upon pillows to let your lungs expand, prop head of bed up using blocks or books, sit in a recliner, avoid liquids at room temperature, and do things that help you to relax. SN discussed that when shortness of breath occurs not to panic and choose one of the following breathing positions: stand with back against a hard surface, sit with feet on the floor and back against the back of the chair, and sit in a chair with arms resting on the table and bend the head slightly forward. It is important to maintain these positions until breathing returns to normal.

Teaching on CHF – Edema reduction / Leg elevation

Congestive heart failure can lead to edema. Edema (or swelling) can occur in the feet, ankles and lower legs. This is caused by standing or sitting with your legs hanging down for extended periods of time. This forces these damaged veins to now have to pump the blood “uphill” which adds strain to already stressed blood vessels.

Swelling is best managed by giving these veins a rest. Activity which requires you to stand or sit with your feet hanging down for long periods of time should be avoided. At regular times throughout the day, you should lie flat and elevate your feet so that they are higher than your heart. This helps those veins to drain the blood and fluid from the feet, ankles and lower legs, since in this position, the blood is now flowing “downhill”.

While standing in one place should be avoided, walking can actually be helpful. Exercising the leg muscles while walking can help “pump” the swelling out of the lower leg. Therefore, plan to take short walks throughout the day.

Teaching on CHF – Energy Conservation

SN discussed with the patient/caregiver the importance of conserving energy to prevent the feeling of being tired. The following tips were given to help use less energy: relax, plan ahead, let people help you, change positions slowly, avoid getting to hot or too cold, rest in between activities, work slowly and don’t feel bad if you can’t finish a task, do not lift heavy objects, use objects that assist you, work at a height that is easy to reach, get plenty of sleep, avoid caffeine, and avoid straining when having a bowel movement. When bathing and dressing use a shower chair, keep clothes near the tub, wear clothes that have zippers and buttons in the front, and do all grooming while sitting. When doing laundry use a machine, avoid ironing or standing in one place for too long, and use a cart to carry laundry to the washing machine. When preparing meals use a stool, put the things you use mostly often close at hand, use electric appliances to avoid working by hand, and when cooking make extra food and freeze some for later.

Teaching on CHF – Infection Prevention

SN discussed with the patient/caregiver that avoiding infections will help keep the heart failure symptoms from getting worse. It was stressed that healthy eating, plenty of rest, having an annual flu shot, and pneumonia shot can help fight infection. SN also discussed the importance of maintaining good hygiene to avoid the possibility of any infections.

Teaching on CHF – Medication Treatment

It was explained that treatment for heart failure includes daily medications, rest, reducing stress, eating less salt, and limiting fluids.
SN discussed the following MEDICATIONS as part of the treatment for heart failure.

Coumadin is a blood thinner which takes the body longer to produce a blood clot. During this therapy the doctor will monitor your PT/INR which is a blood test that tells him how fast your blood is clotting and will allow the doctor to adjust the dose accordingly. It was explained that the medication should be taken at the same time every evening and to avoid foods high in potassium like broccoli and spinach because the work against the medication.

ACE Inhibitors are used to help the blood vessels relax and allow more blood to flow to all parts of the body. It was explained that when taking these medication to check with the doctor before taking any medication over the counter.

Beta-blockers and alpha-blockers affects the number of times your heart beats and the force of the heartbeat. This medication allows the blood vessels to relax and slows down the force of the heartbeat.

Digoxin is used to strengthen the pumping action of the heart. It was further explained that a slow pulse or seeing blues or yellows needs to be reported to the doctor for evaluation of the dose.

Diuretics are taken to help rid the body of excess fluid. It is common to hold fluid when the heart is week. It was explained that when taking diuretics it causes the body to lose potassium in the urine.

Potassium helps to control the heart rhythm. Food can help to assist in the replacement of potassium but often times it is not enough and a supplement will need to be taken as well.

Teaching on COPD – Breathing Exercises

SN discussed with the patient and caregiver the following breathing exercises/opening the airway:
Deep breathing exercises requires using the diaphragm
Postural drainage is a form of positioning body to allow mucus to drain from the airways of the lungs which is only to be done when the stomach is empty,
Cupping/vibration is done by cupping ones hand and thumping on the back to loosen the trapped mucus
Relaxation exercises were discussed with the patient and caregiver to aid in breathing difficulties.
Pursed lip breathing is used when you find it hard to breath and is done by doing the following:

Patient instructed to practice this technique 4-5 times a day at first so pt can get the correct breathing pattern.

Pursed lip breathing technique includes:

1. Relax your neck and shoulder muscles.
2. Breathe in (inhale) slowly through your nose for two counts, keeping your mouth closed. Don’t take a deep breath; a normal breath will do.
3. Pucker or “purse” your lips as if you were going to whistle or gently flicker the flame of a candle.
4. Breathe out (exhale) slowly and gently through your pursed lips while counting to four.
Pt. instructed that with regular practice, the technique will seem natural.

(r)Teaching on COPD – Definition and SS

SN discussed defined COPD for the patient and caregiver as a chronic obstruction/blockage in the lungs which consist of various types such as:
chronic bronchitis, emphysema, asthma, bronchiectasis, and cystic fibrosis.
With the diagnosis of this disease come various changes in the lungs such as: more mucus, less oxygen and may have more carbon dioxide, and less working space to hold air.
SN expressed signs of COPD as: shortness of breath, wheezing, coughing, too much mucus in the lungs, and tightness in your chest. There are several factors that can worsen current lung problems such as: smoking, pollution, weather, household fumes, dust, and allergies.

(r)Teaching on COPD – Energy Conservation

It was discussed with the patient/caregiver the importance of conserving energy.

The following tips were discussed to conserve energy: walk/move slowly, use deep breathing/pursed lip breathing, combine tasks when possible, plan ahead, and don’t try to do everything at once. SN discussed tips for better breathing during sex: be rested, and choose times when breathing is easiest, always wait 2-3 hours after a meal. Keep the room cool, plan to have sex after your bronchodilator has taken effect, when using oxygen use a nasal cannula, don’t rush, if you start to get anxious, stop, relax, and cuddle, make pleasure and affection your goal, whether you reach orgasm or not.

(r)Teaching on COPD – Medications and Side Effects

SN discussed with the pt/cg the following medications and their potential side effects.

Antibiotics are medications that are used to eliminate infections. It was expressed to the patient and caregiver that when a patient has COPD their natural defense is crippled and a mild lung infection can turn into a very serious problem, therefore antibiotics may be prescribed. Common side effects for antibiotics include: nausea/vomiting, headache, and allergic reactions.

Bronchodilators are drugs used to relax the muscles around the bronchial tubes and allowing them to open and allow for ease of breathing. Some side effects of using these drugs are irregular heartbeat, nervousness, restlessness, trembling, bad taste in the mouth, and headache.

Cromolyn sodium is a liquid form for use in a nebulizer or inhaler. It helps to prevent an asthma attack but it is not useful during an attack. Some side effects of this treatment are throat irritation or dryness, bad taste in the mouth, coughing, wheezing, nausea, and nasal congestion.

NSAIDs are a class of asthma medication that helps to block or modify the substance that causes inflammation and constriction of the bronchial airways. Some side effects are general pain, indigestion, muscle soreness, weakness, dizziness, and mouth sores.

Other medications that help to treat COPD are coughing expectorants, Guaifenesin to thin secretions, Steroids, and Steroid inhalers.

(r)Teaching on COPD – Respiratory Infections

SN discussed with the patient and caregiver that respiratory infections can very serious when you have COPD. The warning signs of an respiratory infection are: unusual increase/decrease in the amount of mucus, increase in the stickiness of the mucus, change in color from clear/white to brown/yellow/green/ or blood tinged and unusual increase in shortness of breath. For these signs and symptoms the doctor may prescribe antibiotic therapy. The following signs may require immediate attention by the doctor: more shortness of breath, wheezing, difficulty breathing, more coughing, increase in mucus production, change in mucus color, swelling in ankles/legs/around eyes, sudden weight gain of 3 or more pounds, heart palpitations, unusual dizziness, sleepiness, headaches, vision problems, irritability, trouble thinking, loss of appetite, dehydration, fever over 101, and early morning headaches (not relieved by medication).

(r)Teaching on COPD – Sleep Apnea

SN discussed with pt/cg that sleep apnea and COPD often co-exist. SN defined sleep apnea for the patient/caregiver is when your throat is blocked so air can’t get to your lungs. It is possible to stop breathing for periods of 10 seconds to more than a minute. During these periods you may: snore, gasp, snot, and/or making choking sounds. Sounds of sleep apnea: morning headache, falling asleep while driving, loss of interest in sex or loss of sex function, memory problems, can’t concentrate, and being irritable or anxious. Treatment for sleep apnea was discussed with the patient/caregiver as: the need to use a CPAP machine, oral device to change the position of the tongue and jaw, surgery, and behavior/lifestyle changes.

(r)Teaching on COPD – SS respiratory distress

Patient and caregiver were educated on the following signs of respiratory distress: trouble breathing (dyspnea), breathing faster or slower than usual, trouble breathing unless you are upright, feeling anxious, restless, or irritable, being confused, too tired to do anything, bluish color around lips/nails, and breathing so hard that the skin around the breast bone pulls in when you take a deep breath. SN expressed the following ways to prevent respiratory distress: drink liquids, do breathing/coughing exercises, do chest physical therapy, take oxygen as prescribed, and take medicines as prescribed. SN discussed the importance of eating a well balanced diet and incorporating foods from on food groups. It was further discussed the importance of drinking plenty of fluids and the quality of fluids that the individual drinks.

(r)Teaching on COPD – Traveling with Oxygen

Traveling with oxygen was discussed with the patient/caregiver and the following points were reinforced: know the flow rate, if you have liquid oxygen know the brand name and have the right size adaptor, and always have a written prescription with you. Other important tips to know when traveling with oxygen are: know how to change the tank when it is empty, how to measure the oxygen left in the tank, how to refill the tank, and all the safety measures for oxygen use.

(r)Teaching on DIETS – (DM) High vs Low Glycemic Index

Patient asks “why does my blood sugar rise when eating certain foods?” Patient explained this is most commonly attributed to how fast or slow a food breaks down into simple sugars.

Foods with carbohydrates that break down quickly during digestion and release glucose rapidly into the bloodstream tend to have a high Glycemic index (high GI); foods with carbohydrates that break down more slowly, releasing glucose more gradually into the bloodstream, tend to have a low Glycemic index (low GI).

Patient/CG instructed on low vs high glycemic index (GI) of certain common foods:

Low GI = 55 or less
Medium GI = 56 – 69
High GI = 70 or more

Cereal:
All-bran (US) 50
Oat bran 50
Rolled Oats 51
Bran Buds 58
Mini Wheats 58
Nutrigrain 66
Shredded Wheat 67
Cornflakes 80
Sultana Bran 73
Branflakes 74
Coco Pops 77
Puffed Wheat 80

Bread:
Wheat tortilla 30
Heavy Mixed Grain 45
Whole Wheat 49
Sourdough Rye 48
Sourdough Wheat 54
Croissant 67
Hamburger bun 61
White 71
Bagel 72

Snacks:
Snickers Bar 41
Nut & Seed 49
Sponge Cake 46
Nutella 33
Milk Chocolate 42
Hummus 6
Peanuts 13
Walnuts 15
Cashew Nuts 25
Nuts / Raisins 21
Donuts 76

Beans:
Lentils, Red 21
Lentils, Green 30
Pinto Beans 45
Blackeyed Beans 50

Vegetables:
Eggplant 15
Broccoli 10
Cauliflower 15
Cabbage 10
Mushrooms 10
Tomatoes 15
Chillies 10
Lettuce 10
Sweet Potatoes 48

Fruits:
Bananas 58
Raisins 64
Papaya 60
Figs 61
Pineapple 66

Dairy:
Whole milk 31
Skimmed milk 32
Chocolate milk 42
Sweetened yoghurt 33

Patient and Caregiver (CG) verbalized understanding and have no questions at this time

(r)Teaching on DIETS – Coumadin foods to avoid

Patient instructed on Coumadin therapy to include: taking medication at this same time every evening, if a dose is missed take as soon as possible on the same day, never take double the dose on the next day, and eating increased amounts of green leafy vegetables may work against medication such as:

• Kale
• Spinach
• Brussels sprouts
• Parsley
• Collard greens
• Mustard greens
• Chard
• Green tea

Certain drinks can increase the effect of warfarin, leading to bleeding problems. Avoid or drink only small amounts of these drinks when taking warfarin:

• Cranberry juice
• Alcohol

Additionally, Patient instructed that if they are taking any daily multivitamins to assess level of Vitamin K percentage as this may decrease coumadin’s effectiveness.

Patient also instructed to report any of the following immediately to SN or MD: fever or flu like illness, new pain or swelling in joints, prolonged bleeding from cuts, nosebleeds, or from gums when brushing teeth, black stools or a change in the color of their urine.

(r)Teaching on DIETS – Food Journal

Patient instructed to keep a food journal to determine types and amounts of food eaten.
Patient explained that the information recorded in the food diary will help SN design an eating program to meet caloric needs. Generally, food diaries are meant to be used for a whole week, but studies have shown that keeping track of what was eaten for even 1 day can help make changes in the diet.

GUIDELINES for creating a food journal include:

How much:
In this space indicate the amount of the particular food item eaten. Estimate the size (2″ x 1″ x 1″), the volume (1/2 cup), the weight (2 ounces) and/or the number of items (12) of that type of food.

What kind:
In this column, write down the type of foods eaten. Be as specific as you can. Include sauces and gravies. Don’t forget to write down “extras,” such as soda, salad dressing, mayonnaise, butter, sour cream, sugar and ketchup.

Time:
Write the time of day the food was eaten.

Where:
Write what room or part of the house you were in when you ate. If you ate in a restaurant, fast-food chain or your car, write that location down.

Alone or with someone:
If you ate by yourself, write “alone.” If you were with friends or family members, list them.

Activity:
In this column, list any activities you were doing while you were eating (for example: watching TV or ironing).

Mood:
How were you feeling while you were eating (for example, sad, happy or depressed)?

Helpful Hints:

Do not change your eating habits while you are keeping your food diary, unless your family doctor has given you specific instructions to do so.
Tell the truth. There’s nothing to be gained by trying to look good on these forms. Your family doctor can help only if you record what you really eat.
Record what you eat on all days your doctor recommends.
Be sure to bring the completed forms back with you to your next doctor’s appointment.

Some basic rules to remember:

Write everything down:
Keep your form with you all day, and write down everything you eat or drink. A piece of candy, a handful of pretzels, a can of soda pop or a small donut may not seem like much at the time, but over a week these calories add up!

Do it now:
Don’t depend on your memory at the end of the day. Record your eating as you go.

Be specific:
Make sure you include “extras,” such as gravy on your meat or cheese on your vegetables. Do not generalize. For example, record french fries as french fries, not as potatoes.

Estimate amounts:
If you had a piece of cake, estimate the size (2″ x 1″ x 2″) or the weight (3 ounces). If you had a vegetable, record how much you ate (1/4 cup). When eating meat, remember that a 3-ounce cooked portion is about the size of a deck of cards.

SN gave patient food journal handout and placed in Avida Home Health Chart for easy access. Example:

HOW MUCH WHAT KIND TIME WHERE ALONE/COMPANY ACTIVITY MOOD
————————————————————————————————————————————————————
1 Cookie 3:25PM Kitchen Alone None Depressed

(r)Teaching on DIETS – Low Fat Diet

Patient instructed on low fat diet in 4 categories:

1. Defining the role of dietary fat in disease.

A. Fats provide energy, help in the absorption of fat-soluble vitamins, supply fatty acids, lubricate body tissues, help regulate temperature, and provide protection for some of the most vital organs in our bodies.
B. A healthy level of dietary fat also gives ?avor to our foods and provides a feeling of fullness during meal intake.
C. High levels of fat contribute to many chronic diseases. High-fat diets greatly increase the risk of cardiovascular disease, obesity, and some types of cancer.

2. Current dietary recommendations for a reduced-fat diet.

A. The American Heart Association, Surgeon General, American Cancer Society, and the American Diabetes Association agree on the following:
– Have diets that are low in saturated fat and cholesterol and moderate in total fat.
– Limit fat to 35% or less of the total daily calorie intake.
– Limit saturated fat to less than 10% of total daily calorie intake.
– Limit cholesterol to 300 mg or less daily.

3.. Major sources of dietary fat include:

A. Beef, butter (or margarine), salad dressings (including mayonnaise), cheese, and milk are the top ?ve sources of saturated fat in the average diet.

4. List ways to reduce dietary fat in the diet by:
A. Fruits—avoid avocado, coconut, and olives. Most other fruits are low in fat.
B. Vegetables—eat and prepare vegetables wisely. Avoid fried, creamed vegetables. Avoid cheeses and dressings high in fat on vegetables.
C. Dairy products—select low-fat or fat-free milk, yogurt, and cheese products. Drink two to three servings of low-fat milk and milk products daily.
D. Proteins
– Use plant sources of protein such as beans and nuts.
– Use lean meats and trim any excess fat.
– Remove skin from poultry. Avoid breading or sauces.
– Eat two to three servings of lean ?sh, poultry, lean meats, or other protein sources daily.
– Limit intake of organ meats like liver.
– Limit shell?sh (crab, lobster, etc.) due to high cholesterol levels.

E. Read nutrition fact labels carefully when shopping such as:
– Use low-fat or fat-free salad dressings.
– Choose vegetable oils lower in saturated fats such as canola oil.

F. Season foods with lemon juice, or spices and herbs with label of low fat/low sodium.

G. Cooking and serving foods by doing the following:
– Use fats and oils sparingly when cooking or serving foods.
– Use low-fat sauces on rice, pasta, and potatoes.
– If using some of the commercial fat replacers, be alert for gastrointestinal side effects (cramps and diarrhea).
– Avoid frying foods. Instead, bake, boil, or broil them.

Patient and Cg verbalized understanding and have no questions at this time

(r)Teaching on DIETS – NAS

Reviewed NAS diet with patient this visit.

NAS stands for No Added Salt. A no-added-salt or salt-controlled diet can help control high blood pressure. Even if you are taking medication, it’s important to follow a salt-controlled diet to help the medication work more effectively. The following information was also given on NAS diet:

Use a limited amount of salt in cooking.

Don’t add salt to your food at the table, either at home or when dining out. Most restaurants add salt when preparing food.

Use fresh or dried herbs, spices, and lemon juice to season foods.

Avoid ham, bacon, salt pork, and cheese, because these are made with salt as well as processed and canned foods as these most commonly have high amounts of sodium

When buying convenience foods and processed meats, choose reduced sodium entrees with less than 800 mg of sodium per serving.

Read labels carefully. Some words to avoid include: salt, sodium chloride, monosodium glutamate (MSG), cured, brine, corned, pickled, and smoked. Remember: Canned vegetables are higher in sodium than are fresh or frozen vegetables.

(r)Teaching on DM – Cardiac complications

SN discussed with the patient/caregiver that having diabetes can increase the risk of hypertension, heart disease and stroke. The following was discussed as
ways to help with heart disease: quit smoking, maintain a healthy weight, eat a low-fat diet, control blood pressure, blood cholesterol and fats, ask the
doctor about daily aspirin therapy to prevent heart and blood vessel disease, and exercise regularly. SN also discussed with patient that persons with
diabetes are more prone to poor circulation, kidney disease and infection than patients without diabetes. Patient and caregiver verbalized understanding of
instructions given and voiced no concerns.

 

(r)Teaching on DM – Definition and symptoms

SN discussed Diabetes Type 2 with the patient and caregiver. Disease defined as when the body produces some insulin but doesn’t use it well. Most often it
can be treated by maintain an ideal body weight, diet, and exercise. As a reminder diabetes often runs in families and other members could be at risk. If
meal planning and exercise are not enough to control the disease the doctor will prescribe medication to help control the blood sugar.
Symptoms of type 2 diabetes discussed with patient/caregiver as follows: fatigue, extreme thirst, blurred vision/dizziness, frequent urination, itching
(vaginal, genital), frequent infections (UTI, vaginal, boils, abscesses, and weight changes. Patient and caregiver verbalized understanding of instructions
given and voiced no concerns.

 

(r)Teaching on DM – Depression

SN discussed that dealing with a chronic disease like diabetes is not easy and can lead to depression. The following signs of depressions were explained to the patient/caregiver: feeling worthless all the time, losing weight without trying, gaining weight, insomnia, sleeping too much, being tired all the time or having no energy, feeling on edge all the time or irritable, not wanting to do anything or go anywhere, feeling sad or empty for most of the day, trouble thinking straight, can’t make a decision, and thinking about death or dying or suicide. It was explained that there are various ways of dealing with depression such as: talking, relaxation, thinking positive, physical activity, making time for fun, eating healthy and asking doctor about possibility of depression medications. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Exercise

SN discussed that exercise is a major part of treatment for diabetes and it can do the following:
help the body use insulin better, lower blood glucose, burn calories, improve muscle tone and heart function, improves sense of well-being, and it may decrease the amount of hypoglycemics needed (oral and/or insulin).

It was also explained to remember the following when exercising: warm up before exercise, and cool down afterwards, exercise each day in some way, start slowly and set a pace that is right for you, always wear identification (ID), wear supportive shoes and comfortable clothes, exercise with someone nearby, do not inject insulin (if applicable) into areas which will be used in exercise, and take change or a cell phone with you.

SN discussed the following precautions when exercising: check blood sugar before and after exercise, do not exercise when hypoglycemics are at their peak
(oral and/or insulin). If you experience low blood sugar with exercise tell the doctor as he/she may have to adjust the hypoglycemics for exercising. If your
blood sugar is close to normal ranges before exercising, eat a snack to maintain adequate glucose levels while exercising. If the blood sugar is high
and ketones are present, wait for the sugar to come down before exercising. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Eye exam / Vision complications

SN instructed patient that having diabetes can lead to diabetic retinopathy, cataracts, and glaucoma, therefore it is important to have the eyes dilated
yearly as well as a full eye exam. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Foot care / Neuropathy

SN discussed the importance of good foot care with the patient/caregiver and explained that as a result of diabetes and poor foot care cuts or sores can become ulcers and if left untreated can also result in infection, gangrene or amputation.

To improve blood flow to the feet and legs the patient should: Exercise, sit with uncrossed legs, gently massage cold
feet, wear shoes and socks at all times, moisturize feet but not between the toes and inspect feet daily. If patient cannot inspect feet due to poor
dexterity, patient to use small hand held mirror or have caregiver inspect feet. Patient instructed the following will decrease blood flow: smoking, wearing hose or socks with tight elastic tops, walking barefoot. SN discussed that another complication of diabetes is neuropathy which is nerve damage that most commonly affects the feet and legs. The symptoms can be burning, aching, feel like “pins and needles”, or loss of feeling. It was further explained that with good control of the blood glucose levels some nerve damage can be reversed. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – gum disease

SN instructed patient/caregiver on gum disease and diabetes. Diabetes makes one more prone to gum disease and it was explained to patient/caregiver that
regular checkups, cleaning and flossing daily, and telling the dentist that you have diabetes is very important. Replace your toothbrush at least every three
months, brush dentures daily, and do not smoke or use tobacco products. Patient and caregiver verbalized understanding of instructions given and voiced no
concerns.

 

(r)Teaching on DM – HGB A1C results

This visit SN instructed patient on aspects of the lab test HGB A1C. The A1C test result reflects average blood sugar level for the past two to three months. Specifically, the A1C test measures the percentage of hemoglobin (the protein in red blood cells that carries oxygen) that is coated with sugar (glycated). The higher the A1C level, the poorer the blood sugar control and the higher risk of diabetes complications. Reviewed results of HGB A1C test with patient and CG. Patient had HGBA1C level of _____ . Chart given to patient to review:

HGB A1C levels:
5.0 = 97
6.0 = 126
7.0 = 154
8.0 = 183
9.0 = 212
10.0 = 240
11.0 = 269
12.0 = 298
13.0 = 326
14.0 = 355

*A1C levels obtained from Mayo Clinic as of Jan. 30, 2013

Patient also instructed that the American Diabetes Association currently recommends an A1c goal of less than 7.0%, while other groups such as the American Association of Clinical Endocrinologists recommend a goal of less than 6.5%.

Studies have shown that there is a 10% decrease in relative risk for every 1% reduction in A1c. If a patients starts off with an A1c of 10.7and drops to 8.2,, they have managed to decrease their risk of micro-vascular complications by about 20%. The closer to normal the A1c, the lower the absolute risk for micro-vascular complications.
Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

(r)Teaching on DM – High Vs. Low Glycemic Index

Patient asks “why does my blood sugar rise when eating certain foods?” Patient explained this is most commonly attributed to how fast or slow a food breaks down into simple sugars.

Foods with carbohydrates that break down quickly during digestion and release glucose rapidly into the bloodstream tend to have a high Glycemic index (high GI); foods with carbohydrates that break down more slowly, releasing glucose more gradually into the bloodstream, tend to have a low Glycemic index (low GI).

Patient/CG instructed on low vs high glycemic index (GI) of certain common foods:

Low GI = 55 or less
Medium GI = 56 – 69
High GI = 70 or more

Cereal:
All-bran (US) 50
Oat bran 50
Rolled Oats 51
Bran Buds 58
Mini Wheats 58
Nutrigrain 66
Shredded Wheat 67
Cornflakes 80
Sultana Bran 73
Branflakes 74
Coco Pops 77
Puffed Wheat 80

Bread:
Wheat tortilla 30
Heavy Mixed Grain 45
Whole Wheat 49
Sourdough Rye 48
Sourdough Wheat 54
Croissant 67
Hamburger bun 61
White 71
Bagel 72

Snacks:
Snickers Bar 41
Nut & Seed 49
Sponge Cake 46
Nutella 33
Milk Chocolate 42
Hummus 6
Peanuts 13
Walnuts 15
Cashew Nuts 25
Nuts / Raisins 21
Donuts 76

Beans:
Lentils, Red 21
Lentils, Green 30
Pinto Beans 45
Blackeyed Beans 50

Vegetables:
Eggplant 15
Broccoli 10
Cauliflower 15
Cabbage 10
Mushrooms 10
Tomatoes 15
Chillies 10
Lettuce 10
Sweet Potatoes 48

Fruits:
Bananas 58
Raisins 64
Papaya 60
Figs 61
Pineapple 66

Dairy:
Whole milk 31
Skimmed milk 32
Chocolate milk 42
Sweetened yoghurt 33

Patient and Caregiver (CG) verbalized understanding and have no questions at this time

 

(r)Teaching on DM – How to check blood sugar/Ketones

SN discussed the steps to check blood sugar:
1- wash hands,
2- turn on the machine,
3- insert test strip,
4- press the lancet to the side of the fingertip and activate lancet,
5- milk a drop of blood onto test strip,
6- hold pressure to finger, and
7- obtain reading and treat according to the order.
SN instructed pt on ketoacidosis. It was explained that because the body uses glucose for energy that when the glucose is low, the body will begin to break
down fat. This can lead to ketoacidosis. If left untreated death or coma could result. To manage high blood sugars test both the blood and urine. If the
glucose is higher than 240 and ketones are present call the doctor for further directions and drink plenty of sugar-free fluids. Patient and caregiver
verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Hyperglycemia

SN instructed patient/caregiver on Hyperglycemia which is elevated blood sugar. The following symptoms were given:
thirst, nausea, vomiting, frequent urination stomach cramps, blurred vision, sweet fruity breath, feeling tired, flushed skin, itching, deep, rapid breathing and
unconsciousness.
It was explained that some of the cause of high blood sugar could be:
skipped insulin or not taking the correct amount, not taking the correct amount of oral medication, illness or infection, severe stress or trauma, overeating,
eating concentrated sweets, or insulin that has been damaged by the heat or cold or expired. Patient and caregiver verbalized understanding of instructions
given and voiced no concerns.

 

(r)Teaching on DM – Hyperglycemia Prevention

SN discussed preventing hyperglycemia with the patient/caregiver as follows: inject the right amount of insulin at the right times each day, test your
blood sugar regularly, see the doctor if you feel ill or have an infection, test your urine for ketones when the glucose is high or when you are sick, check
insulin for expiration date before use, follow meal plan, and do not exercise if your blood sugar is high or ketones are present. To manage a high blood
sugars test both the blood and urine. If the glucose is higher than 240 and ketones are present call the doctor for further directions and drink plenty of
water. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Hypoglycemia

SN discussed with the patient/caregiver hypoglycemia which is low blood sugar. The symptoms of low blood sugar are listed as:
shaky, slurred speech, sweaty, staggering, headache, confusion, hungry, convulsions, dizzy, unconsciousness, fast heartbeat,
irritable/moody, and numbness/tingling around the mouth, lips, and/or tongue

It was explained that because sometimes one does not recognize these signs it is important to teach others the signs of low blood sugar
and to always wear an ID like the Medic Alert bracelet.

It was explained that a below 70 blood sugar is considered low. Some of the causes are: too much hypoglycemics (insulin or oral), too little food- like skipping or delayed,
extra exercise without extra food, and alcohol. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Hypoglycemia prevention and treatment

SN discussed the following ways to prevent hypoglycemia: take correct insulin, never skip or delay a meal, test blood regularly, learn how to relate it
to exercise, always carry a good sugar source and a healthy snack. It was discussed that when treating blood sugar you first check the sugar, then you drink
fruit juice or a soda, 6 or 7 candies, or glucose tablets. Wait for 15 minutes and retest if the sugar is low give more juice wait and repeat the blood sugar.

Once the blood sugar is above 70 it is important to eat a meal or a snack if your meal is not close. SN discussed that if the patient is unconscious
or unable to swallow an emergency Glucagon kit will need to be used. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Insulin administration

SN discussed and demonstrated the following steps of giving an insulin injection:
1- wash hands with soap and water,
2- check the bottle of insulin to be sure it is and not out of date,
3- mix the insulin by rolling the bottle between your hands, however non NPH insulin is not rolled,
4- wipe of top of insulin bottle with alcohol wipe,
5- remove syringe from packing and take of both end caps off,
6- pull out plunger until it reaches the number on the syringe that matches how many units you are to take,
7- insert the needle into the bottle,
8- push the plunger down to fill the bottle with air,
9- pull back on the plunger to the exact dose that is ordered,
10- make sure there are no air bubbles in the syringe,
11- remove the needle,
12- clean the injection site with alcohol and insert the needle at a 90 degree angle while pinching the skin,
push the plunger down and then remove the needle and apply pressure.

SN discussed preventing infections at the insertion site by keeping the skin around the area free of bacteria, and don’t
breathe on the skin once it is scrubbed for insertion. Patient and caregiver verbalized understanding of instructions given
and voiced no concerns.

 

(r)Teaching on DM – Random Daily Glucose Check

Patient asked when he / she checks glucose levels and patient reported, “every day but usually before breakfast”. Patient instructed that although this is an acceptable practice it is best to check glucose levels at random intervals. Diabetics should check their blood sugar levels as such:
Diet Controlled Diabetic: Check glucose levels 3 times per week
Oral Hypoglycemic Controlled Diabetic: Check glucose levels 1 time per day
Insulin Controlled Diabetic: 3 times per week.
The following schedule was proposed for a Oral Hypoglycemic Controlled Diabetic:
Monday – Check blood sugar before breakfast
Tuesday – Check blood sugar one hour after breakfast
Wednesday – Check blood sugar before lunch
Thursday – Check blood sugar one hour after lunch
Friday – Check blood sugar before dinner
Saturday – Check blood sugar one hour after dinner
Sunday – Check blood sugar before bedtime
Patient states he / she would try this schedule next week and notify SN for any glucose levels above 250

 

(r)Teaching on DM – Stress

SN discussed that stress can directly affect the blood sugar by causing it to go up or down. Learning to manage stress that causes these changes is how to
cope which involves either fixing the problem, getting rid of the problem, or learning to live with it. SN explained that it is important to learn to manage
your stress in a healthy way. Patient and caregiver verbalized understanding and voiced no concerns at this time.

 

(r)Teaching on DM – Travel

SN discussed with the patient/caregiver the importance of planning ahead when traveling and asking one’s self the following: will the travel interfere with
meal time, how will the change in time zones affect my medicines and meals, and how to store insulin so that it does not get too hot or too cold.

It was reinforced to the patient/caregiver that all diabetic supplies should be carried with them on the plane and that they should always travel with extras in
case of breakage.

It was also discussed that when flying it is important to verify the new federal aviation guidelines for transporting diabetic medication
and supplies to ensure no issues arise during travel. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on DM – Weight management

SN instructed patient/caregiver on diabetes and weight management. It was explained that with extra weight it is harder for the body’s insulin to work.
Maintaining a healthy diet and exercise will help to lose the weight and control the blood sugar. SN discussed planning ahead when eating out. If your meal
will be delayed by an hour or two take hypoglycemics (oral and/or insulin) as scheduled and eat a snack. The meal will take place of the snack. It was also
discussed that when ordering a meal choose from the healthy or lite menu and to eat the serving size and ask for a box to take the rest home. Avoid salt and
use lemon wedges or vinegar to season the food. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

(r)Teaching on FOLEY CATHETER – Basic Care

Patient and caregiver instructed to always wash hands before handling the catheter, clean the skin around catheter daily with soap and water, and perform bag changes weekly or prn. Patient also instructed not to wear clothes that may rub against the catheter, or pull at the catheter because it is held in place with a balloon filled with water and pulling may cause pain and/or blood to appear in the bag. Patient and caregiver instructed to use stat lock at all times and notify SN if stat lock comes off. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

(r)Teaching on FOLEY CATHETER – How to change large cath bag to leg bag

Pt. given leg bag and instructed on method of changing large catheter bag to leg bag by :
1) Washing hands and donning gloves
2) Clamping catheter bag
3) removing large catheter bag and sliding on leg bag
4) securing leg bag with leg straps
Pt. to change bag back at night as leg back can only hold a limited amount of urine. Pt. returned demonstration on how to do switch from leg bag to large catheter bag and vice versa

(r)Teaching on FOLEY CATHETER – SS of UTI

Patient instructed on the signs and symptoms of a urinary tract infection (UTI) with a urinary catheter as follows: foul-smelling urine, dark/cloudy in color, blood in the urine, and fever. SN also discussed with the patient tips to avoid a UTI as followed: drink plenty of fluids each day clean your genital area well each day, and wipe from front to back after using the restroom. Patient verbalized understanding and voiced no concerns.

(r)Teaching on HTN – Complications

SN discussed the problems that can occur after years of uncontrolled blood pressure and no treatment as follow: damage to the heart, blood vessels, brain, eyes, and kidneys. The risks without treatment are: heart failure, heart attack, stroke, kidney failure, reduced eyesight, hypertensive crisis which would cause severe headache and/or vomiting. Patient and caregiver verbalized understanding and voiced no concerns at this time.

 

(r)Teaching on HTN – DASH diet

SN discussed the DASH diet which stands for Dietary Approaches to Stop Hypertension with the patient/caregiver. This diet consists of the following: foods low in sodium, low in fat, low in cholesterol, high in fiber, potassium, calcium, magnesium, and moderately high in protein. Patient and caregiver verbalize understanding and voiced no concerns at this time.

 

(r)Teaching on HTN – Definition

SN defined high blood pressure to the patient/caregiver as when the force of the blood moving through the arteries is too high, it can cause damage the artery walls and reduce blood flow to body tissues. As the heart pumps blood, the pressure on the artery walls is at its highest and at this peak it is called the systolic pressure. Between the heartbeats, the arteries are more relaxed as the blood flows to all parts of the body. The relaxed pressure is called the diastolic pressure. Blood pressures are recorded using 2 numbers the top number is the systolic pressure and the bottom number is the diastolic pressure. SN discussed the types of blood pressure as follows: primary or essential hypertension which tends to run in the family and secondary hypertension which is caused by a medical problem. It was explained to be diagnosed with hypertension the reading must be high 3 times or more. The following is considered a high blood pressure: the top number is 140 or greater and the bottom number is 90 or greater. Patient and caregiver verbalize understanding and voice no concerns at this time

 

(r)Teaching on HTN – Energy conservation

SN discussed with the patient/caregiver that saving energy can help keep blood pressure under control. The following tips were given to help conserve energy: relax and spread activities throughout the day and at your own pace, plan ahead, let people help you, rest in between activities, work slowly, do not loft heavy objects, work at a height that is easy to reach, get plenty of sleep, try not to bend over quickly, get up slowly from bed, and keep things close by.

 

(r)Teaching on HTN – Follow up and keeping BP records

The importance of follow-up care was discussed with the patient and caregiver. Both were instructed to take blood pressure often and keep a record of the results. This will allow the doctor to adjust your treatment accordingly. Patient and caregiver verbalized understanding and voiced no concerns.

 

(r)Teaching on HTN – Medications

SN discussed with the patient/caregiver the types of medication for HTN that the doctor may prescribe to help control the blood pressure. The prescribed medication may need to be taken for life or for a short period of time, depending on any treatments being used at the same time. Never double up on medication if a dose is missed or skipped. The following examples were given as possible side effects of taking blood pressure medicine: weakness, headaches, feeling tired, dry cough, weight loss, depression, dry mouth, chest pain, nausea/vomiting, swelling, dehydration, slow pulse, changes in bowel and bladder function, frequent urination, blood in your urine, change in urine color, diarrhea, and constipation.
Furthermore, pt/CG instructed to read the labels of any OTC (over the counter) medications as many of them have a high sodium content which cause the blood pressure to rise.

 

(r)Teaching on HTN – Self monitoring at home

SN discussed with the patient/caregiver that monitoring their blood pressure at home is important. They should understanding the following when taking home blood pressures: it is lower when you are sleeping and raises upon waking up and becoming active, talking and walking and eating make the blood pressure go up, sudden stress or pain can cause a rise in blood pressure, exercising hard or getting excited can raise blood pressure, and being uneasy or fearful will raise blood pressure. SN discussed the most popular device to take home blood pressures are the digital blood pressure devices. The following tips are important regarding a digital blood pressure device: check the device with your doctor or nurse to make sure it is accurate, read the instructions carefully before using, and store the device at room temperature. It was reinforced to record all blood pressures on the blood pressure chart provided and it should be taken to every doctor visit. Patient and caregiver verbalized understanding and voiced no concerns at this time.

 

(r)Teaching on HTN – stress

SN discussed with the patient/caregiver that stress can raise blood pressure sharply and may add to the cause of high blood pressure. The following tips were given to help when stress is rising: get away from whatever is causing stress, breathe slowly and deeply to relax, have a massage, take a brisk walk, soak in a warm bath, watch a funny video, talk to a friend, meditate or do relaxation exercises, mow the lawn, weed the flower beds, or plant new flowers, and walk to the dog. Patient and caregiver verbalized understanding and voiced no concerns.

 

(r)Teaching on HTN – Weight reduction

SN discussed with the patient/caregiver that weight can directly affect the blood pressure because it causes the heart to work harder. It was discussed that at 10% over the ideal body weight it will be important to get to a healthy weight. The following tips were discussed for losing weight: lose weight gradually 1 to 2 pounds a week, choose food items from all food groups for a well-balanced diet, read food labels and choose foods low in fat and calories, ask the nurse for meal plan, get a cookbook with low-salt recipes, and exercise regularly. It was discussed when losing weight follow these tips: limit smoked or pickled foods, eat small portions, keep low-calories snacks on hand, avoid sweetened drinks, choose low-fat or no-fat dairy products, reduce the amount of saturated fat in your diet, and eat more fruits and vegetables and whole grains.

V – Teaching on MEDS –Antacid (5)

Patient and CG instructed that medication of _____ is in the category of Antacid (Box 5)

Action: Reduce total acid in the GI tract, increase gastric pH, increase gastric mucosa! barrier strength.
Side Effects: Anemia, anorexia, constipation, electrolyte imbalances, fecal impactions, hypercalciuria, hypertension, interference with other drugs, kidney stone, malaise, mental depression, muscle weakness, NN/D, renal failure. Magnesium containing: diarrhea, hypermagnesemia in renal failure, laxative effect Aluminum containing: aluminum intoxication, constipation, encephalopathy, hypophosphotemia, osteomalcia, possible intestinal obstruction,
Contraindication: Sensitivity, sodium restriction. hypercalcemia, hypercalcinuria. GI hemorrhage, obstruction. colostomy, Ileostorny, dehydration. ventricular fibrillation. cardiac disease Cautious use in renal impairment, gastric outlet obstruction, elderly, decreased bowel activity, history of CHF.
Drug Interaction: Tetracycline. Interference with drug absorption.
Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

V – Teaching on MEDS – Analgesics: Opioids (3)

Patient and CG instructed that medication of _____ is in the category of Analgesics – Opioids (Box 3)

Action: Opioid drugs work by binding to opioid receptors in the brain, spinal cord, and other areas of the body. They reduce the sending of pain messages to the brain and reduce feelings of pain.
Side Effects: Burred vision, constipation, bradycardia, confusion, dizziness, drowsiness, dry mouth, dyspnea, respiratory depression, hypotension, nausea, vomiting, physical and/or psychological dependance and fatigue.
Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

V – Teaching on MEDS – Anti Ulcer (23)

Patient and CG instructed that medication of _______ is in the category of Anti Ulcer (Box 23)

Action: Inhibits / suppresses basal gastric secretions by inhibiting histamine (h2 Blocker) also by inhibiting the ATPase enzyme system or by venous other methods protects the gastric mucosa
Side Effects: Abdominal pain, alopecia, angina, appetite changes, bleeding, confusion, constipation, depression, dermatological changes, Diarrhea, dizziness, dry mouth, fever. flatulence, gynecomastia, headache, hematura, irregular heart rate, mood changes, nausea, neutropenia, rash, reversible impotence, seizure, somnolence, unusual visual disturbances, vomiting, weakness.
Contraindication: pregnancy, lactation, hepatic impairment, decrease dose in renal or hepatic failure. May interact with diazepam, phenytoin, warfarin, antacids, tricyclic antidepressants, calcium channel blockers and others too numerous to list. Refer to specific drug if indicated.
Drug Interaction: Ketoconazole, itraconazole, cilostazol, hepatic microsomal enzyme inducing drugs, Aspirin, alchohol, antacids, Warfarin, Nicotine.
Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

V – Teaching on MEDS – Antianxiety (7)

Patient and CG instructed that medication of _____ is in the category of antianxiety (Box 7)
Action: Modes of action vary with agent. Used for sedation, insomnia, anxiety disorder, anticonvulsant and muscle relaxant
Side Effects: BP changes, cardiac changes, dizziness, drowsiness, dry mouth, fatigue, GI effects, headache, psychiatric/behavioral problems, urinary incontinence/retention, suicidal tendencies, withdrawal or rebound syndrome when DC
Contraindications: renal, hepatic and respiratory impairment. Severe cardiac disease, hyperthyroidism, Potential for abuse
Drug Interactions: CNS depressants, antipsychotic agents, antacids, antiarrhythmics, anticonvulsants and anticoagulants
Food Interactions: Food may delay absorption
Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

V – Teaching on MEDS – Antibiotic / Antibacterial (10)

Patient and CG instructed that medication of _____ is in the category of antibiotic / antibacterial (Box 10)
Action: Growth of microorganism is inhibited as a result of inhibition of folic acid production or mucoprotein or cell wall synthesis
Side Effects: abdominal pain, anaphylaxis, anemia, anorexia, anuria, depression, dermatitis, dizziness, dysuria, dyspepsia, flatulence, headache, hematuria, increased BUN, nausea, vomiting, diarrhea, photosensitivity, taste disturbance
Contraindications: use caution with asthma, renal, and hepatic disease, psychoses, convulsive disorders, myesthenia gravis, milk protein hypersensitivity
Drug Interactions: anticoagulants, salicylates, phenylbutazone, tolbutamide, chlorpropramide, cimetidine, antacids
Food Interactions: If stomach upset persists, try using yogurt if no dairy allergies present

 

V – Teaching on MEDS – Anticoagulant (12)

Action: Decreases conversion of prothrombln to thrombin, decreases the prothrombin time or decreases the production of Vitamin K.

Side Effects: Alopecia, arterial and heart valve calcification, asthma, decreased renal flow. GI bleed, heavy menstrual flow, hematuria, hemorrhage, lacrimation, leukopenia, N/V/D, rash, rhinitis, thrombocytopenia. urticaria

Contraindications: Bleeding disorders, hepatic or renal disease, psychosis, pregnancy, lactation, TB. Use cautiously in allergies, elderly, CHF, diabetes, alcoholism, pregnancy, postpartum, salicylates. Hypersensitivity to low molecular weight heparin, beef, pork products, use caution with sulfite sensitivity.

Food Interactions: Vitamin K-rich foods may decrease effects of oral anticoagulants (e.g., leafy green vegetables, broccoli).

Drug Interactions: Many drug interactions. Consult additional reference If side effects, interactions differ from those listed.

 

V – Teaching on MEDS – Antidepressant (14)

Patient instructed that medication of _____ is in the category of antidepressant (Box 14)
Action: medication differs with each medication but treatment of depressions, bipolar disorders, obsessive compulsive disorder, easting disorder and adjunctive to pain therapy.
Side Effects: Agitation, BP changes, diarrhea, cardiac changes, dizziness, drowsiness, dry mouth, headaches, impaired motor skills, photosensitivity, tremors, suicidal tendencies, weight gain or loss
Contraindications: BP problems, renal/hepatic disease, seizure disorders, elderly, diabetics, cardiac disease
Drug Interactions: CNS depressants, other antidepressants, alcohol (medication is metabolized in the liver)
Food Interactions: Tyramine rich foods (fermented meat, aged cheese, red wine, sauerkraut, and soy sauce) for MAOI inhibitor class of antidepressants
Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

V – Teaching on MEDS – Antidiabetic (15)

Patient and CG instructed that medication of _____ is in the category of antidiabetic (Box 15)
Action: medication differs with each medication but treatment is done through increasing sensitivity to insulin, reduction of hepatic glucose production, reducing or delaying carbohydrate digestion and glucose absorption.
Side Effects: anemia, anorexia, dark urine, headache, heartburn, photosensitivity, metallic taste, hypoglycemia, swelling of hands and feet and weakness
Contraindications: hepatic or renal disease, cardiac disease, adrenal or pituitary insufficiency (metformin), inflammatory bowel disease, intestinal obstruction. Avoid ethanol
Drug Interactions: CNS depressants, ethanol, MAO inhibitors, erythromycin, ketoconazole
Food Interactions: None
Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

V – Teaching on MEDS – Antihypertensive (17)

Patient and CG instructed that medication of _____ is in the category of antihypertensive (Box 17)
Action: Various actions which may include depletion of dopamine, decrease renin, angiotension, relaxation of vascular smooth muscle or the decrease of norepinephrine. Angiotenson enzyme inhibitors, calcium channel blocking
Side Effects: abdominal pain, anemia, angina, asthma, bradycardia, CHF, constipation, hyperkalemia, impotence, insomnia, myocarditis, nausea/vomiting/diarrhea, orthostatic hypotension, photosensitivity, rash, tachycardia, weakness
Contraindications: heart block, pregnancy, lactation, depression, MI, use cautiously in hepatic, renal and cardiac disease, CVA, geriatric patients,
Drug Interactions: All antihypertensives, digoxins, antidiabetics, lithium, NSAIDs, ACE inhibitors, antacids, potassium sparing drugs, calcium channel blockers: (quinidine), carbamazepine, cyclosporine, rifampin, tricyclic antidepressants, cimetidine, ranitidine, theophylline, beta blockers, adrenergics, eplerenone, St. Johns Wort.
Food Interactions: None

 

V – Teaching on MEDS – Bronchodilator (25)

Patient and CG instructed that medication of _____ is in the category of Bronchodilator (Box 25)
Action: Stimulates the central nervous system at the cortex or stimulates beta receptors

There are 2 types of bronchodilator medications. Long and short acting.
Long acting bronchodilators include:
Albuterol (AccuNeb, Proventil HFA, Ventolin HFA)
Alupent (Metaproterenol
Levalbuterol (Xopenex)
Pirbuterol (Maxair)

Short acting bronchodilators (aka rescue inhalers) include:
Advair and Symbicort
ProAir (albuterol sulfate)
Serevent (salmeterol)
Foradil (formoterol)
Perforomist

Side Effects: anorexia, anxiety, arhythmias, bornchospasms, diuresis, circulatory failure, GI bleed, hypokalemia, insomnia, muscle cramps, nausea, vomiting, palpitations, tachycardia, restlessness, tremor
Contraindications: renal, cardiac, or hepatic disease, diabetes
Drug Interactions: antidepressants, adrenergics, CNS stimulants, antihistamines, levothyroxine, antihypertensives, potassium wasting diuretics
Food Interactions: None

Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding.

 

V – Teaching on MEDS – Diuretic (28)

Patient and CG instructed that medication of _____ is in the category of Diuretic (Box 28)
Action: Decreased water reabsorption in the kidneys resulting in diuresis
Side Effects: anorexia, arrhythmia, confusion, constipation, convulsions, depression, diarrhea, dysuria, frequency, gout, headache, hearing loss, hepatic failure, hypokalemia, hyponatremia, hypovolemia, lethargy, muscle weakness, nervousness, orthostatic hypotension, paresthesia, rash, tinnitus, vomiting.
Contraindications: Anuria, hepatic or severe kidney failure, COPD, electrolyte imbalance – May be enhanced by cholestryamine, diazaoxide, lithium and steroids
Food Interactions: potassium sparring agents, Vitamin K-rich foods (leafy green vegetables like broccoli), salt substitutes may result in hyperkalemia

 

(r)Teaching on MEDS – Coumadin

Patient instructed on Coumadin therapy to include: taking medication at this same time every evening, if a dose is missed take as soon as possible on the same day, never take double the dose on the next day, and eating increased amounts of green leafy vegetables may work against medication. Patient also instructed to report any of the following immediately to SN or MD: fever or flu like illness, new pain or swelling in joints, prolonged bleeding from cuts, nosebleeds, or from gums when brushing teeth, black stools or a change in the color of their urine.

(r)Teaching on PAIN ! – Alternative Treatments

SN instructed pt.CG that pain medicine is the most common treatment for pain. However, alternative therapies can help ease different types of pain.

MOIST HEAT THERAPY: decreases pain caused by sore muscles and muscle spasms by increasing the blood flow.

COLD THERAPY: Treats pain caused by inflamed tissues or other swelling. It was stressed that using this therapy should only be for 20-30 minutes at a time. It was further discussed not to apply ice to any area that has received radiation therapy or any area that has decreased feeling in it.

MASSAGE THERAPY: Relieves pain by relaxing the muscles, improving the blood flow, and releasing tension. It was discussed that lowering tension in the muscles and the amount of stress you feel can help relieve pain.

RELAXATION EXERCISES – Reduces pain levels by decreasing tesnion as well. Common relaxation exercises include: deep breathing, progressive muscle relaxation, and inner journey.

Further options to control pain: set realistic goals every day, try to get some form of exercise each day, listen to audio tapes of comedians and try using humor and laughter to cope with your pain, plan short rest periods throughout your day, visit or talk with family and friends, if you are an animal lover, get a pet and spend time with it, and do something fun at least once a day. Patient and caregiver verbalized understanding and voiced no concerns at this time.

(r)Teaching on PAIN ! – Complications

SN discussed pain management with the patient and caregiver. Pain was described as an unpleasant feeling that affects the body and mind which various for each individual.

It was explained that if pain is not controlled it can: keep you from moving around and being active, keep you awake, make you lose your appetite, cause you
to not be able to concentrate and think clearly, make you not want to be around other people, cause you to feel anxious and distress, make you depressed,
make you take longer to heal, cause nausea or an upset stomach, make you heart beat faster than normal, add stress to your life, make you not enjoy life, and
cause fatigue.

(r)Teaching on PAIN ! – Early Treatment (good) vs Later Treatment (bad)

SN discussed that most pain can be controlled with medicine or alternative treatments. Patient explained that if you treat the pain early (when your pain level is at a “5” or lower on a scale of 1-10), you will most likely get faster relief and more control. Conversely, if you wait until your pain level is at a “6” or higher on a scale of 1-10, then your pain level goal will be slower to achieve and harder to control. As a rule of thumb pain therapy (medication or alternative) can usually cut your pain level in only half. The quicker the response to pain the better. If the treatment is not working, it is important to tell the nurse and doctor so that the dose can be changed or additional medication can be ordered.

(r)Teaching on PAIN ! – Goals

SN discussed with patient that the goals of controlling pain are to: have you feel no pain or keep it at a level you can stand. To do this, be sure your medicines are effective
by taking them at the prescribed time, the correct doseage, try to control any side effects from your medication, use non-drug treatments, eat a healthy diet
every day, feel rested after you sleep, improve the way you get through each day, and make life enjoyable again.

(r)Teaching on PAIN ! – Pain control plan

SN stressed the importance of discussing pain management with the health care team to facilitate a recovery. The following hints were discussed to help with the pain control plan: be prepared, take action, take your pain medicine early, ask your doctor about other medicines if the current one is not working, talk to the nurse about pain medication, and stick with the pain control plan.

(r)Teaching on PAIN ! – Weather

Patient states he /. she is having more pain due to the recent weather changes. Patient instructed that the reason for his increased pain is due to the fluctuation of barometric pressure. Barometric pressure is the weight of the atmosphere that surrounds us. Patient instructed to imagine the tissues surrounding the joints to be like a balloon, high barometric pressure that pushes against the body from the outside will keep tissues from expanding. When the weather changes and we have rain, the barometric pressure changes and the pressure that was holding the tissues from expanding is let loose which leads to increased pain.

(r)Teaching on SAFETY – Bathroom

Patient instructed on bathroom safety in the home. SN discussed storing bathroom items within reach, installing grab bars by the toilet/tub/shower, using a special bench/seat for the shower, and using a non-slip rubber mat in the tub/shower. Patient advised to help prevent burns keep the water heater setting at 120 degrees Fahrenheit. SN discussed with the patient the option of installing a hand-held shower head to assist with the ease of bathing. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on SAFETY – Electrical

SN educated patient/caregiver on the following tips for electrical safety: unplug your toaster, hair dryer, and other appliances when not in use, don’t use electrical cords that are cracked or frayed, don’t overload outlets- if a plug is needed use a power strip that has a surge protector, and know where the circuit breaker is. If a fuse blows or a circuit trips more than once, it may be overloaded. Patient and caregiver cautioned against using extension cords that can overload the circuits and cause fires. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on SAFETY – Fire

SN discussed with patient/caregiver fire safety in the home which should include: the use of smoke detectors, fire extinguishers, and an escape plan. Tips for using smoke detectors: have at least one outside each bedroom on each floor of the home, test batteries monthly, and replace batteries once a year or sooner if the detector is making a chirping noise. Carbon monoxide detectors were also discussed with the patient/caregiver. It was further discussed having an available fire extinguisher on every floor in the house or more if mobility is an issue. Patient/caregiver instructed that all fire extinguishers are labeled according to the fire they can extinguish; the one for the home should be Type ABC which can be used for all types of fires. It was reinforced to the patient/caregiver that fire extinguishers are used for small fires and if a large fire starts to call 911. They were also instructed that when using a fire extinguisher make sure they have their back to an exit in order to leave safely. Instructed to use the following tips when using the fire extinguisher: pull the pin out of the handle, aim the nozzle at the base of the fire, squeeze the lever and handle together, and sweep the nozzle back and forth so you spray the entire fire. Fire extinguisher should be inspected monthly to verify that the pin is in place, the yellow arrow on the dial is in the green zone, and the nozzle is on the extinguisher.
Reviewed with the patient/caregiver ways to protect against fire as follows: speak with fire department regarding special services for homebound individuals, don’t smoke or light a match in bed, store oxygen in a canisters upright in a clean place, don’t store oxygen canisters around fire or heat even if empty, use a fireplace screen, store kindling at least 3 feet from your fireplace, keep space heaters at least 3 feet from anything that might catch fire, don’t leave candles burning, turn your stove or space heater off when you leave your house, and keep matches/lighters away from children. It was further discussed tips for getting out of a house because of fire as follows: have an escape plan, stay close to the ground as you can, breathe better-cover your nose and mouth with a wet towel, feels doors before you open them, and if your clothes catch fire- stop, drop, and roll. SN discussed with patient/caregiver tips for creating a fire escape plan as follows: have at least 2 escape plans for each room- including the basement, make note of which rooms have only one way out, review escape plans with everyone in the home, have all members of your home practice the escape plans, designate a meeting place outside the home if there is a fire, and let the fire department know if you are unable to get out of the bed on your own in case there is a fire in the home. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on SAFETY – Home (inside)

Patient instructed on maintaining a safe environment in the home. SN instructed patient on safe floor coverings such as short-pile carpet, indoor/outdoor carpet, non-skid surfaces, and maintaining a pathway clear of shoes, throw rugs, or any item that cause patient to trip. Patient instructed to secure electrical cords away from the walking path, and add night lights to the bathroom, bedroom, and hallways to maintain good lighting to prevent accidents. Patient verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on SAFETY – Home (outside)

Patient instructed on safety outside the home. SN discussed with patient when walking or exercising outside to do so in a familiar and safe area. Patient advised that if they are unfamiliar with the area or surrounding to go into a store or office building and ask for directions. Be alert when outside the home distractions such as earphones that can inhibit your ability to hear traffic, animals, and etc. SN discussed with patient carrying a cell phone when outside the home and not carrying things that may tempt a thief. Discussed with the patient always carrying valid identification, emergency numbers, and letting someone know where they are going. Patient and caregiver verbalized understanding of instructions given and voiced no concerns

 

(r)Teaching on SAFETY – Kitchen

Patient instructed on maintaining/cooking safely in the kitchen. SN discussed not wearing oxygen (if applicable) and maintaining the proper clothing when cooking. Patient instructed to turn the handles of pots and pans away from the edge of the stove, keeping the toaster and other electrical appliances away from water, and maintaining the water heater setting below 120 degrees Fahrenheit to avoid burns. Patient and caregiver verbalized understanding of instructions given and voiced no concerns.

 

(r)Teaching on SAFETY – Oxygen

SN discussed the use of oxygen with the patient/caregiver and instructed them that it is considered medicine and should not be changed without a doctor’s order. The following tips were give to using oxygen safely: store oxygen away from heat, direct sunlight, or a pilot light, if using cylinders secure them so that they cannot tip over, no smoking in the room where oxygen is used or stored, do not increase liter flow without asking your doctor, do not use oxygen near an open flame, you can use electric appliances, and do not use any petroleum-based products. It was discussed that when traveling with oxygen it is important to know the length of the trip so that arrangements can be made to ensure you have enough oxygen.

(r)Teaching on WOUNDS – General – Definition and Types

SN defined a wound as an injury to the body’s tissue that causes a tear or break and damages the tissue underneath. A wound can be caused by the following: a disease process, a trauma/injury, pressure, too much moisture, or surgery. There are two types of wounds: acute wound- heals in a short time and chronic wound- takes longer to heal due to other health problems.

 

(r)Teaching on WOUNDS – General – Infection Treatment

SN discussed with the patient/caregiver that to fight the infection the doctor may prescribe one or more of the following: antibiotics, antifungal agents, antiviral drugs, and anti-inflammatory agents. The patient/caregiver were reminded that for the medication to work best it must be taken as it is prescribed by the doctor.

 

(r)Teaching on WOUNDS – General – Pain

Pain can make wound care difficult following these steps can help: covering the wound with a dressing, change body position and if you have pain when cleaning or changing the dressing take pain medicine. SN discussed taking pain medication about 30 minutes to one hour before the dressing change which will make doing so easier. Patient and caregiver verbalize understanding and voiced no concerns at this time.

 

(r)Teaching on WOUNDS – General – Risk Factors

SN discussed with the patient/caregiver that the following risk factors were given for developing a wound: not eating a healthy diet, dehydration, poor circulation, diabetes, unable to control bowel/bladder, inability to move, unable to feel pain/pressure, steroid use, immune system problems, in the bed or wheelchair most of the time, older, IV line or port, anemic, and have areas of the body exposed to moisture for a prolonged time.

 

(r)Teaching on WOUNDS – General – SS of Infection

SN discussed with the patient/caregiver that an infection to the wound will slow the healing process. The following signs of infection were explained to the patient/CG: thick, green or yellow drainage, bad smelling odor from the wound after cleaning, the wound becomes larger or remains the same size for 2 weeks or longer, redness or warmth around the wound, tenderness of the area around the wound, swelling, fever or chills, weakness, confusion or having difficulty concentrating, and rapid heartbeat. SN further discussed with the patient to notify care team if patient cannot follow care plan (eating balanced diet, maintain compliance with nursing instructions, feeling malaise or sickness).

 

(r)Teaching on WOUNDS – General – High protein diet

SN discussed with patient the importance of a high protein diet for patients with open wounds. A diet high in protein is crucial for granulation tissue formation thereby reducing wound healing time and assisting with wound closure. Sources of protein include:
beef
chicken
salmon
tuna
peanut butter
protein shakes
yogurt
almonds
Patient states he will try to include more high protein foods in his diet

(r)Teaching on WOUNDS – General – Vitamin C

SN instructed patient on importance of Vitamin C in the wound healing process because of its role in collagen formation. Vitamin C is a co-factor in proline and lysine hydroxylation, a necessary step in the formation of collagen. Hydroxyproline and hydroxylysine are essential for stabilizing the triple helix structure of collagen with strong hydrogen bonds and crosslinks (i.e. it creates a matrix or scaffold for new tissue to form into and become viable)

Without this stabilization, the structure disintegrates rapidly. Vitamin C also provides tensile strength to newly built collagen; otherwise, new tissue could not stretch without tearing. Tensile strength is important in wound healing because healed wounds are susceptible to future skin breakdown. Vitamin C also is required for proper immune system function, a consideration in patients with open wounds. Sources of Vitamin C include:
guava
kiwi
red sweet pepper
strawberries
papaya
green pepper
vegetable juice cocktail
cantaloupe
pineapple
sweet potato
mango
Pt verbalized understanding and states he will incorporate more foods with Vitamin C into his current diet

 

 

(r)Teaching on WOUNDS – Pressure Ulcers – Cause and Prevention

SN discussed with the patient/caregiver that the causes of pressure ulcers are due to: pressure, moisture, friction, and shearing. The following tips were discussed to preventing pressure ulcers: change positions often, use pressure relief devices, avoid friction or shearing, keep clean and stay dry, eat a healthy diet, drink plenty of fluids, and check your skin around bony areas. Some of the following pressure relief devices were discussed: gel, water, air, or foam mattress to help spread weight evenly, pillow or wedge between the knees to keep from touching, using a bed cradle to keep the sheets from touching the feet or legs, using a drawsheet with a 2 person transfer, and a special cushion for a chair or wheelchair. The importance of staying as active as possible was discussed with the patient and caregiver to promote healing. SN discussed the importance of checking skin daily and reporting the following warning signs: if you have light skin, look for pink, red or dusky colored areas that do not turn white when touched, if you have dark skin, look for blue or purple areas, areas that feel hard or warm, blisters, scrapes or other broken skin, swelling, and pain over bony areas.

Teaching on Compression Stockings

SN instructed the patient and CG on aspects of compression stockings – Compression stockings are a simple noninvasive treatment for varicose veins, chronic venous insufficiency, and lymphedema.
The treatment compresses superficial veins to promote the flow of blood through the leg veins and prevent the accumulation of fluid (edema) in the tissues of the legs.
To be effective, compression stockings must be worn regularly.

Compression stockings, which are made from an elastic fabric, fit most tightly around the ankles and gradually become looser farther up the leg. The treatment compresses superficial veins to promote the flow of blood through the leg veins and prevent the accumulation of fluid (edema) in the tissues of the legs. Compression stockings are used for:

Chronic venous insufficiency (CVI);
Varicose veins;
Lymphedema; and
Deep vein thrombosis.

However, patients with impaired arterial circulation in the legs should not use compression stockings.

Compression stockings require daily use to be fully effective, They may initially cause great discomfort when they press against existing or recently healed ulcers. However, by wearing stockings briefly at first and then gradually increasing the duration of wear, the compression stockings become easier to keep compliant with.

Stockings should be worn at all times during the day. Stockings are to be put on in the morning before getting out of bed and wear them all day until bedtime. Do not wear stockings overnight

 

-Teaching on Constipation Relief

SN instructed pt to try the following for constipation relief:

Drink two to four extra glasses of water a day (unless fluid restricted).
Try warm liquids, especially in the morning.
Add fruits and vegetables to your diet.
Eat prunes and/or bran cereal.

Do not use laxatives for more than two weeks without calling your doctor, as laxative overuse can aggravate your symptoms.

Call SN if:

You have blood in your stool.
You are losing weight even though you are not dieting.
You have severe pain with bowel movements.
Your constipation has lasted more than 3 days.

Teaching on EYE drop installation

SN instructed pt/CG on proper eye drop installation by performing the following steps:

1 Wash your hands thoroughly with soap and water.
2 Check the dropper tip to make sure that it is not chipped or cracked.
3 Avoid touching the dropper tip against your eye or anything else – eyedrops and droppers must be kept clean.
4 While tilting the head back, pull down the lower lid of eye with your index finger to form a pocket.
5 Hold the dropper (tip down) with the other hand, as close to the eye as possible without touching it.
6 Brace the remaining fingers of that hand against your face.
7 While looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid. Remove your index finger from the lower eyelid.
8 Close the eye(s) for 2 to 3 minutes and tip the head down as though looking at the floor. Try not to blink or squeeze the eyelids.
9 Place a finger on the tear duct and apply gentle pressure.
10 Wipe any excess liquid from the face with a tissue.
11 If you are to use more than one drop in the same eye, wait at least 5 minutes before instilling the next drop.
12 Replace and tighten the cap on the dropper bottle. Do not wipe or rinse the dropper tip.
13 Wash the hands to remove any medication.

Teaching on Falls Prevention

SN educated the patient/caregiver on the following tips to prevent falls: install sturdy rails along stairs or steps, apply non-skid backing to keep throw rugs from sliding, install non-skip stripes in the tub/shower, arrange furniture so that it is not in the walking path, use a bath seat when showering, install grab bars in the shower/tub or next to the toilet, steps, entryways and ramps should be well marked and easy for one to see, have eyes checked at least once a year, exercising to improve strength/balance, make sure home is well lit, pay attention to your surroundings and the uneven surfaces, wet floors, clutter or other things that may put you at risk, and slow down and take your time. Patient and caregiver verbalize understanding and voiced no concerns at this time.

Teaching on Incontinence

SN discussed with the patient/caregiver helpful products and devices that can help with incontinence. Some of the products discussed with the patient/caregiver are: absorbent garments, garments with alarms, bedside toilets, urinals, bedpans, and bedding underpads.

SN discussed that there is a possibility the physician could order the following devices to assist with incontinence.
Straight intermittent catheter – Used to drain the urine from the bladder and then removed.
Indwelling catheter – Used to drain urine from the bladder and remains in place and is only removed when needing to be replaced.
External collection device – Attaches to the penis or vulva but does not enter the body. Device is attached with special medical tape and urine flows from the tube into a drainage bag.

To avoid infection and odors, the perineal area must be kept clean. The area must also be checked for signs of irritation (red or dark areas). The proper technique for cleaning the female and male perineal area was discussed with the patient/caregiver as:
MALES:
1. If not circumcised, hold shaft of penis and gently retract foreskin.
2. Using circular motion, wash tip of penis (if using soap, avoid getting it into the urethral opening)
3. Repeat cleaning from urethral opening outward until clean; if needed, return foreskin to natural position
4. Wash shaft and testicles. Pay attention to folds in the groin area.
5. Rinse (if soap used) and pat thoroughly dry. Note: Pre-moistened wipes are preferable
6. Using a separate cloth or pre-moistened wipe, wash lower abdomen or any other areas that may have been exposed to urine or feces.
7. Reposition to side-lying position, cleanse anal and buttocks area with cloth or pre-moistened wipe
8. Rinse (if soap used) and pat dry.
9. Apply barrier cream in a thin layer to all skin fold or irritated areas as necessary
10. Reposition patient and make them comfortable

FEMALES:
1. Help patient flex knees and widen legs if possible or turn her on her side with legs flexed.
2. Carefully wash one side of the genitals at a time from front to back.
3. Repeat procedure using a fresh cloth. Pay attention to the folds in the groin area.
4. Rinse (if soap used) and pat thoroughly dry. Note: Pre-moistened wipes are preferable.
5. Using a separate cloth, wash lower abdomen or any other areas that may have been exposed to urine or feces.
6. Reposition to side-lying position, cleanse anal and buttocks area with cloth or pre-moistened wipe.
7. Wash area from front to back.
8. Rinse (if soap used) and pat dry.
9. Apply barrier cream in a thin layer to all skin fold or irritated areas as necessary.
10. Reposition patient and make them comfortable.

Patient/caregiver verbalizes understanding and voiced no concerns at this time.Inc

Teaching on Bladder Re-Training (Timed Voiding)

 

SN instructed patient / CG on Timed voiding which means that the bladder is emptied on a regular basis — not only when the urge to void is felt. One of the most successful

non medical therapies for this problem includes the bladder retraining program, combined with Kegel exercises, which will allow you to gain significant control over your bladder symptoms.
Pelvic floor (Kegel) exercises can help strengthen some of the muscles that control the flow of urine. These exercises are used to treat urge or stress incontinence. To do Kegel exercises:

Squeeze the same muscles you would use to stop your urine. Your belly and thighs should not move.
Hold the squeeze for 3 seconds, then relax for 3 seconds.
Start with 3 seconds, then add 1 second each week until you are able to squeeze for 10 seconds.
Repeat the exercise 10 to 15 times a session. Do three or more sessions a day.

An important part of this program is to keep a log of urinary input and output. A simple reminder of normal values are:

Normal daily fluid intake:
1500 – 2000 cc (50 – 70 ounces)
Normal daily urine output: 1200 – 1500 cc (40 – 50 ounces)
Normal voiding volumes: 210 – 300 cc (7 – 10 ounces)
Normal bladder capacity for sens
ation to void: 300 cc (10 ounces)
Largest bladder volume is usually in the morning: 400 – 500 cc (12 – 15 ounces)

Your goal with the Timed Voiding Program is to increase your bladder’s capacity and prolong the time interval between urinating up to an average of three or four hours.

Timed voiding prevents the bladder from overfilling and sending urgent messages to empty. This allows individuals with urge incontinence to have some control over their bladder, instead of their bladder being in control. It’s also helpful in situations where the impulse to empty isn’t received, as with individuals with a neurological impairment or in some cases of dementia.

If you have difficulty reaching the bathroom without leaking urine, squeeze your pelvic floor muscles (Kegel exercises) before you get out of bed and count slowly to FIVE. Get out of bed and walk normally to the bathroom. You do not want to rush to the toilet and reinforce your bladder’s bad behavior!
After you have emptied your bladder as completely as possible, set your clock or timer for the pre-determined voiding interval which will be every __2___ Hours. When that time arrives, go to the bathroom and attempt to urinate, EVEN IF YOU DO NOT HAVE THE NEED TO EMPTY YOUR BLADDER !
After you have urinated, reset your timer for the same time interval, and repeat this throughout the entire day. If you need to urinate in between these times intervals, or you need to get up in the middle of the night to urinate please do so.

Remember: If you are unable to suppress your urge to urinate and you urinate at an UNSCHEDULED time, you should still attempt to urinate at the SCHEDULED time, even if it is only a few minutes later.

Ways to remember your intervals – Timed voiding watches that can be programmed to vibrate at regular intervals of time are sensational in implementing any timed reminder program. Some people use reminder watches not only for timed voiding, but for taking medication, checking blood sugar, making carpool schedules, etc. If a watch is not available simply use a wall clock and remember YOUR time frame to go and uriante

In each of these weeks, you will increase the time intervals between the scheduled voiding times by 15 to 30 minutes each week. Our goal is to allow you to be able to comfortably hold your urine for three to four hours

TIPS FOR SUCCESS:
1. Believe that you WILL be successful
2.Remember to do your KEGEL pelvic floor exercises after EACH voiding.
3. Follow the above program.
4.Give the program a full SIX weeks to see benefit.
5.Don’t become discouraged by setbacks. Your bladder symptoms are likely to be worse when:
b.You are preoccupied with many other things
c.You are tense or nervous
d.You are about to start your menstrual period
e.You are outside on cold, rainy or windy days
6.Avoid alcohol, citrus juices, or drinks with caffeine.
7.Avoid going to the toilet “just in case”. Follow your schedule.
8.Avoid constipation by using fiber or bulk stool laxatives.

    Teaching on Oasis Requirement – Signs of Heart Attack

    SN instructed patient that when (s)he starts feeling chest pain, tightness, or squeezing in the chest to take nitroglycerin(if prescribed) or aspirin. If patient has nitroglycerin prescribed, take nitroglycerin one time every 5 minutes. If no relief after 3 doses, call 911
    SN also instructed the patient of the following symptoms that 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. If signs and symptoms present, patient to call 911 immediately

    Teaching on PICC line dressing care

    SN instructed on Preventing Infection & Dressing Changes of a PICC line:
    A secure, clean and intact dressing is essential to prevent catheter migration and infection. The dressing should be changed every seven days or more if needed. It is often helpful if a friend or family member is taught how to change the dressing, even if home care is used, to insure the dressing remains dry as a moist dressing is the perfect breeding ground for infection.

    When dressing changes are being done, insure that the anchoring devise, Biopatch and injection caps are also changed at that time.

    Dressings should be inspected daily. If it is wet, soiled or leaking, it must be changed. Dressings should be removed by loosening the adhesive, using alcohol if necessary. Scissors should never be used due to the possibility of cutting the catheter in error.

    Hands should be washed properly with an antiseptic solution prior to handling the catheter or supplies. Scrub hands thoroughly. Be sure to include the palms back of hands, fingers and spaces between them and fingernails. Rinse them with running water with hands pointing down so the water flows downward. Dry them with a dry paper towel.

    Clean the catheter caps with alcohol swab pads prior and post each use.

    Teaching on Pulmonary Toiletry

    Patient instructed on the following aspects of pulmonary toiletry – pt to control coughing episodes during toiletry. Uncontrolled coughing can make pt. short of breath.

    Pt. to sit up straight in a chair when attempting these coughing exercises and to have a tissue on hand to catch any expectorant.

     

    1. Sit up straight on a hard-backed, stable chair, relax.

    2. Take in 2-3 deep breaths through your nose and exhale slowly through pursed lips.

    3. Fold your arms across your abdomen.

    4. Take in a comfortable deep breath through your nose.

    5. Lean forward, pressing your arms against your abdomen and cough while leaning forward.

    6. Relax, rest 5-10 minutes

    7. Perform 2-3 times Q 2 Hours

    Also, thick, sticky mucus is difficult to cough up, especially with a weakened cough reflex. It is important that pt drink enough fluids to keep your mucus thin and loose.
    Humidify home or at least the room the pt sleeps in / room pt spends most time in. Keep humidifier clean, as they are a possible source of infection.
    Do not smoke – smoking takes moisture out of mucus and makes the mucus thicker.

    Teaching on Pursed Lip Breathing

    Pt. instructed on pursed lip breathing techniques and rationale:

    Pursed lip breathing is one of the simplest ways to control shortness of breath. It provides a quick and easy way to slow your pace of breathing, making each breath more effective.

    Pursed lip breathing does the following:

    Improves ventilation
    Releases trapped air in the lungs
    Keeps the airways open longer and decreases the work of breathing
    Prolongs exhalation to slow the breathing rate
    Improves breathing patterns by moving old air out of the lungs and allowing for new air to enter the lungs
    Relieves shortness of breath
    Causes general relaxation

    Patient instructed to use this technique when she has the following:

    During the difficult part of any activity, such as bending, lifting or stair climbing.

    Patient instructed to practice this technique 4-5 times a day at first so she can get the correct breathing pattern.

    Pursed lip breathing technique includes:

    1. Relax your neck and shoulder muscles.
    2. Breathe in (inhale) slowly through your nose for two counts, keeping your mouth closed. Don’t take a deep breath; a normal breath will do.
    3. Pucker or “purse” your lips as if you were going to whistle or gently flicker the flame of a candle.
    4. Breathe out (exhale) slowly and gently through your pursed lips while counting to four.
    Pt. instructed that with regular practice, the technique will seem natural.

    Teaching on SCAMS

    SN instructed patient / caregiver that as a savvy consumer, you should always be on the alert for shady deals and scams. To avoid becoming a victim, keep these
    things in mind:

    I. A deal that sounds too good to be true usually is! Be wary of promises to
    fix your credit problems, low- interest credit card offers, deals that let you
    skip credit card payments, work-at-home job opportunities, risk- free investments, and free
    travel.

    2. Don’t share personal information with someone you don’t trust.

    3. Beware of payday and tax refund loans. Interest rates on these loans are usually excessive. A
    cash advance on a credit card may be a better option.

    4. Read and understand any contract, legal document or terms of service before you sign or
    click “I Agree”. Do not sign a contract with blank spaces or where the terms are incomplete.
    Some contracts include a clause that prohibits you from taking legal action and require you to
    engage in mandatory arbitration with a company in the case of a dispute.

    5. Get estimates from several contractors for home or car repairs. Make sure the estimates are
    for the exact same repairs for a fair comparison.

    6. Before you buy, make sure you understand and accept the store’s refund, return and early
    termination/ cancellation policies, especially for services and facilities that charge monthly fees.

    7. When paying for your purchases, double-check the final price. If you think the price that has
    been charged is incorrect, speak up.

    8. When shopping online, look for the padlock icon in the bottom right-hand comer of your
    screen or a URL that begins with “https” to ensure that your payment information is transmitted
    securely,

    9. Don’t buy under stress. Avoid making big-ticket purchases during times of duress {e.g.,
    coping with a death or debt).

    10. If you are having difficulty making payments on loans, notify your lender immediately so
    that you can work out a payment plan.

    patient and caregiver verbalize understanding and have no questions at this time

    Teaching on SS of UTI

    Patient instructed on the signs and symptoms of a urinary tract infection (UTI) as follow: burning pain with urination, frequent urination, foul-smelling urine, dark/cloudy in color, blood in the urine, bladder spasms, and fever. SN also discussed with the patient tips to avoid a UTI as followed: drink plenty of fluids each day, empty your bladder before and after sex, clean your genital area well each day, wipe from front to back after using the restroom, and don’t hold your urine empty your bladder as soon as you feel the need. Cranberry juice or pills if no contraindications. Patient verbalized understanding and voiced no concerns.

    Teaching on Medical Equipment and Supplies

    SN discussed the following safety tips in terms of medical equipment/supplies with the patient/caregiver: always follow the supplier and nurse’s instructions for safe handling, use, and storage of supplies, keep medical equipment in a safe place, keep children/pets away from medical supplies, keep medical equipment in a safe place, if you use equipment that runs in electricity-don’t move it from one outlet to another without asking the nurse, have a back-up plan if the electricity goes out, keep track of the supplies you use so you don’t run out, and when moving portable medical equipment that moves with you remember to do so safely. Patient and caregiver verbalize understand and voiced no concerns at this time.

    Teaching on Medical Waste Disposal

    Patient instructed on the correct disposal of medical waste as follows: needles, syringes, lancets, or any other sharp object should be placed in a hard plastic or metal container with a screw-on lid or tightly secured lid. Any of these containers can be found in your home, be sure not to use a container that you plan to recycle. Patient instructed to secure the lid of the container with heavy tape, such as duct tape, prior to disposing of it in the garbage. SN discussed other medical waste and its disposal as follows: used dressings/bandages, medical gloves, underpads (Chux), used ostomy products, IV tubing only can all be placed in the plastic back that can be securely closed and placed in the garbage. Patient verbalized understanding and voiced no concerns.

    Sn instructed on post op precautions: After knee replacement surgery, you should not pivot or twist on the involved leg for at least six weeks. Also during this time, when lying in bed, you should keep the involved knee as straight as possible. Kneeling and squatting also should be avoided soon after knee joint replacement surgery. Your physical therapist will provide you with techniques and adaptive equipment that will help you follow guidelines and precautions while performing daily activities. 

    Remember, not following the given precautions could result in the dislocation of your newly replaced joint. The following tips should make your recovery at home easier.

    •Stair climbing should be kept to a minimum. Make the necessary arrangements so that you will only have to go up and down the steps once or twice a day.

    •A firm, straight-back chair is extremely helpful in adhering to these joint precautions. Recliners should not be used.

    •To help avoid falls, all throw rugs should be removed from the floor and rooms should be kept free of unnecessary debris.

    •Enthusiastic pets should be kept far away until you have healed,

    Note Templates

    Admitted __ year old hispanic female/male to home health services patient of Dr.__. Pt. admitted to HHA due to__ Pt has a medical hx of __
    This visit, Pt identified by address and facial recognition. Received patient sitting in chair in no apparent distress while ____ who is primary CG answered door. With gloves on, VS and full body assessment performed. Observations recorded in previous sections.

    Patient’s vital signs on admission were   =>  stable/ abnormal.

    Patient is awake, alert and oriented X3, however, is forgetful. Lung sounds are CTA with no signs of respiratory distress. Patient reports having a regular bowel movement today. Pulses are palpable and no edema noted to BLE.

    Pt. lives with ___ in a ___. Medications are managed by ___. Patient ambulates using _________. Gait is abnormal, patient seems weak. PT and OT to evaluate. SNV for education on disease process, medications and evaluate effectiveness of therapist as well as evaluation of HHAide. Patent to receive services of PT/OT due to ___ Pt. also to receive HHAide for assistance with ADL’s due to ___. Patient and caregiver were instructed on Plan of Care for SN , PT, OT, HHAide and agree with POC.

    SN instructed pt on safety measures such as  having  a safe environment in the home. SN instructed patient on safe floor coverings such as short-pile carpet, indoor/outdoor carpet, non-skid surfaces, and maintaining a pathway clear of shoes, throw rugs, or any item that cause patient to trip. Patient instructed to secure electrical cords away from the walking path, and add night lights to the bathroom, bedroom, and hallways to maintain good lighting to prevent accidents. Patient verbalized understanding of instructions given and voiced no concerns.

    Instructed patient on medication_____________ (please include side effects and when to call MD)…. OR ….  Patient and CG instructed that medication of  _____ is in the category of Analgesics – Opioids (Box 3)
    Action: Opioid drugs work by binding to opioid receptors in the brain, spinal cord, and other areas of the body. They reduce the sending of pain messages to the brain and reduce feelings of pain.
    Side Effects: Burred vision, constipation, bradycardia, confusion, dizziness, drowsiness, dry mouth, dyspnea, respiratory depression, hypotension, nausea, vomiting, physical and/or psychological dependance and fatigue.
    Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding..

    Instructed patient on pain management such as _________________ (please list specifics)…. OR…. Instructed patient on pain management such as that most pain can be controlled with medicine or alternative treatments. Patient explained that if you treat the pain early (when your pain level is at a “5” or lower on a scale of 1-10), you will most likely get faster relief and more control. Conversely, if you wait until your pain level is at a “6” or higher on a scale of 1-10, then your pain level goal will be slower to achieve and harder to control. As a rule of thumb pain therapy (medication or alternative) can usually cut your pain level in only half. The quicker the response to pain the better. If the treatment is not working, it is important to tell the nurse and doctor so that the dose can be changed or additional medication can be ordered.

    MD DC instructions reviewed and it was noted that: (insert ORTHO guidelines here is applicable OR any DC instructions not previously mentioned).

    Safety check reveals deficiencies in the following: low couch, 2 smoke detectors needed throughout home, no grab bars in bathroom, no raised toilet seat, no non-skid mat in shower and no shower chair. Patient also noted to have clutter throughout home and low light levels in hallway and living room. Patient instructed on all deficient areas and patient states he will correct all areas to avoid falls/injuries

    Pt./cg instructed on the following: criteria for Medicare Home Health, OASIS/Agency Privacy Notice, Rights of the Elderly, Agency-Rights and Responsibilities Number, Informed Consent & Financial Responsibility, Advanced Directives, Compliant Procedure/State Hotline, Abuse/Neglect APS Hotline, Emergency Preparedness/Management, Services Provided w/24Hr RN on-call, Discharge Planning/HHABN, Pt/cg participation in POC; goals of care and frequency of disciplines ordered. Instructed patient and caregiver to call agency with any questions or concerns, however, to call 911 or report to ER with any emergencies.

     

    Pt identified by address and facial recognition. Received patient sitting in chair in no apparent distress while ____ who is primary CG answered door. With gloves on, VS and full body assessment performed. Observations recorded in previous sections. Patient currently suffers from …

    Patient instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient verbalized understanding

    Patient and CG instructed to call agency for any questions, falls or concerns or to call 911 for any emergencies. Patient and CG verbalized understanding

     

    SENSORY STATUS

    SN to repeat instructions as often as necessary to attain 100% understanding

    SN to repeat instructions as often as necessary to attain 100% understanding from patient

    PAIN

    patient will have pain level of 3 on a scale of 1-10 by end of cert period

    CARDIO

    Normal sinus rhythm: S1, S2.  No abnormal sounds, murmur and thrill. Patient denied chest pain, headache and dizziness. No edema present.

    RESPIRATORY

    No sputum or cough noted, Patient instructed to take 5 deep breaths every 1-2 hours with coughing on 5th breath to retain and hopefully increase lung capacity

    NEUROLOGICAL

    Neuro function remains stable. No changes noted since the last visit. Patient remains homebound secondary to limited gait, use of assistive device, and remains risk for falls. Patient require assistance to leave home safely.

    GU

    -GU function reports to be stable. Patient denies difficulty with voiding and s/s of UTI.

    –Patient urinated without incident and has normal bowel movements. instructed to report change in urination pattern including burning or pain, urgency or frequency, foul odor or blood as this could indicate UTI. instruct to increase fluids and fiber in diet if hardened less frequent stools are experienced and to report no BM after 3 days so interventions may be placed.

    MUSCULOSKELETAL

    Patient denied fall or injuries.  Assistive devices being used as instructed. No clubbing, cyanosis or deformity noted.

    PSYCHOSOCIAL

    No changes in home environment or level of support from caregiver. Adequate coping skills noted.

    INTEGUMENTARY

    -Integument warm and dry. Good skin turgor noted. Skin care remains appropriate.

    –Pt is at risk for skin breakdown per braden scale, instruct on frequent position changes, offloading pressure and ways to reduce friction and shearing

    DIGESTIVE / NUTRITION

    Abdomen is soft, non-tender and non-distended; normal bowel sounds. No changes in appetite and bowel function.

    Post-Hospital certification done on __ year old hispanic female/male for resumption of care of home health services. Patient is under the services of Dr.__ and has a medical hx of __. Pt. went to __ hospital for the following reason: __
    Using gloves, vitals taken and head to toe assessment done. Patient is awake, alert and oriented X3, however, is forgetful.
    Lung sounds are CTA with no signs of respiratory distress. Patient reports having a regular bowel movement today. Pulses are palpable and no edema noted to BLE. Patient will have the following services : SNV for education on disease process, medications and ___ , PT for ___, OT for ___, ST for ___ MSW for ___ HHAide for __
    Pt/ cg instructed on advance directives, HIPPA, basic safety, infection control, and development of emergency plan. Instructed patient and caregiver to call agency with any questions or concerns, however, to call 911 or report to ER with any emergencies.

    (BASIC) Discharged __ year old male/female from home health services as goals have been met. Pt. was seen for disease process teaching and evaluation including DM, HTN, unstable gait, Rheumatoid arthritis and GERD. PT reached maximum functioning potential and pt DC’d on __. Therapy services have been completed. ___ manages medications without difficulty. Skilled nursing is no longer needed. Patient lives with __.  Received patient sitting in chair in no apparent distress. Using gloves, vitals taken and assessment completed. Patient is awake, alert and oriented to person and place.. All skin is clean, dry and intact with no visible wounds noted. Lungs are CTA and no respiratory distress noted. Bowel sounds are present and patient reports having regular bowel movements usually daily. Pulses are palpable and no edema noted to extremities. Reviewed medications with __ and patient and no changes have been made. Patient will be following up with PCP in one month. Patient continues to use __ for ambulation.  Instructed to take all medications as ordered and to call us if home health services are ever needed again. Patient and __ verbalized understanding and collaboration of all instructions given. All questions answered. Supplies: gloves

     

    (ORTHO) Discharged __ year old male/female from home health services as goals have been met. Pt. was seen for disease process teaching and evaluation including DM, HTN, unstable gait, Rheumatoid arthritis and GERD. PT reached maximum functioning potential and pt DC’d on __. Therapy services have been completed. ___ manages medications without difficulty. Skilled nursing is no longer needed. Patient lives with __.  Received patient sitting in chair in no apparent distress. Using gloves, vitals taken and assessment completed. Patient is awake, alert and oriented to person and place. All skin is clean, dry and intact with scar formation in place to ___. No dehiscence noted. Lungs are CTA and no respiratory distress noted. Bowel sounds are present and patient reports having regular bowel movements usually daily. Pulses are palpable with slight edema noted to ___.  Reviewed medications with __ and patient and no changes have been made. Patient will be following up with surgeon  in one month. Patient able to ambulate without assistance / Patient continues to use __ for ambulation.

    Patient Given Hip Discharge Instructions

    Maintain Hip Precautions x 3 months. Take Aspirin or other prescribed blood thinner for 6 weeks post operatively. TED hose to be worn for 6 weeks, remove at night. Gabapentin to be taken for 30 days. Oral antibiotics before dental work. No soaking and continue home exercise program as prescribed. Also instructed to take all medications as ordered and to call us if home health services are ever needed again. Patient and __ verbalized understanding and collaboration of all instructions given. All questions answered.

     

    Patient Given Knee Discharge Instructions

    Immobilizer to be worn at night for 6 weeks. TED hose to be work for 6 weeks. Take Aspirin or other prescribed blood thinner for 6 weeks post operatively. Gabapentin to be taken for 30 days. Oral antibiotics before dental work. No soaking. Vitamin E can be massaged daily into scar and continue home exercise program as prescribed. Also instructed to take all medications as ordered and to call us if home health services are ever needed again. Patient and __ verbalized understanding and collaboration of all instructions given. All questions answered.

     

    Patient Given Shoulder Discharge Instructions

    Gabapentin to be taken for 30 days. Oral antibiotics before dental work. Exercise as prescribed by your MD. Follow up with your MD as directed. Also instructed to take all medications as ordered and to call us if home health services are ever needed again. Patient and __ verbalized understanding and collaboration of all instructions given. All questions answered.

    MD Protocols

    Patient instructed of Dr. Tait’s TKA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    All DME items are available and ordered if needed ((FWW, 2-in-1 commode, etc.,)
    If patient has a Procellara (silver) dressing, do not remove for 7 days from initial application. After that do routine incision care as follows:
    Paint incision with iodine, cover with dry sterile dressing. Change DAILY until drainage stops.
    Staple removal for INITIAL TKA: 14-21 days post-op with home health nurse and then apply full length steri-strips.
    Staple removal for REVISION TKA: 21 days and can be done by MD or RN.
    Nurse to draw PT/INR every Wednesday (if patient on coumadin).

    TED hose to stay on for approximately 6 weeks until seen by physician. May remove at night for comfort.
    Patient to wear knee immobilizer at night.
    CPM 2hours 2x/day. Start at 0-75 degrees.
    7 days post-op, patient may SHOWER ONLY if wound/incision shows NO drainage. Use liquid antibacterial soap.

     

    Patient instructed of Dr. Tait’s THA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    All DME items are available and ordered if needed ((FWW, 2-in-1 commode, etc.,)
    If patient has a Procellara (silver) dressing, do not remove for 7 days from initial application. After that do routine incision care as follows:
    Paint incision with iodine, cover with dry sterile dressing. Change DAILY until drainage stops.
    Staple removal for INITIAL THA: 14-21 days post-op with home health nurse and then apply full length steri-strips.
    Staple removal for REVISION THA: 21 days and can be done by MD or RN.
    Nurse to draw PT/INR every Wednesday (if patient on coumadin).

    TED hose to stay on for approximately 6 weeks until seen by physician. May remove at night for comfort.
    Patient to wear knee immobilizer at night.
    CPM 2hours 2x/day. Start at 0-75 degrees.
    7 days post-op, patient may SHOWER ONLY if wound/incision shows NO drainage. Use liquid antibacterial soap.

    Patient also instructed to on hip precautions which is to have NO flexion at the hip greater than 90 degrees, no internal rotation of the hip (don’t point toes in towards midline) and no adduction of the hip (no leg crossing). Maintain hip precautions x 12 weeks

    TED hose to stay on for approximately 6 weeks until seen by physician. May remove at night for comfort.
    7 days post-op, patient may SHOWER ONLY if wound/incision shows NO drainage. Use liquid antibacterial soap.

     

    Patient instructed of Dr. Tait’s TSA (total shoulder arthroplasty) protocols as follows:
    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    Procellera Dressing: Do not remove Procellera dressing until 7 days after it was applied, then change dressing DAILY until incision is dry.
    Regular Dressing: If you have a normal dressing and not Procellera then change after a few days after DC home. After the incision is dry you may DC dressing.
    Staple removal at MD office 2 weeks post-op.

    TED hose to be worn during the day for 2 weeks until seen by MD. After MD follow up visit, patient may take stockings off at night.
    Patient may shower 5 days after surgery. Use “dial” type antibacterial soap. Carefully dry incision and change dressings daily after showering. Avoid totally submerging the area until 3 weeks post-op.
    Wear sling AT ALL TIMES. If arm is removed for bathing/showering/changing clothes/therapy, someone MUST support the arm. Do not let the arm drop to one side.

    Patient instructed of Dr. Baldauf’s TKA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    Change dressing with dry sterile dressing until drainage has stopped.

    Staple removal post-op day 10-14 IF incision is clean and intact.
    SN to instruct patient on self administration of SQ anticoagulant injection if applicable.

    TED hose to stay on for approximately 6 weeks until seen by physician.
    7 days post-op, patient may SHOWER ONLY if wound/incision shows NO drainage.
    Medications: EC ASA 325 BID x 30 days, Colace 100 mg OTC.

    Patient instructed of Dr. Baldauf’s THA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation.

    Change dressing with dry sterile dressing daily until drainage has stopped.
    Staple removal for THA: 10-14 days post-op if incision is clean/dry/intact.

    Instruct patient on self-administration of SQ anticoagulant injections if ordered.
    Review hospital DC instructions with patient.

    TED hose to stay on for approximately 3 weeks until seen by physician. May remove at night for comfort.
    Patient may SHOWER ONLY if wound/incision shows NO drainage.

    OK for stool softener 100 mg OTC

     

    none

    Patient instructed of Dr. Hillock’s TKA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    Change dressing with dry sterile dressing daily for 14 days.
    Staple removal by doctor post-op 3 weeks (physician prefers to take out staples at MD visit)
    Atrixia 2.5 mg SQ once daily

    SN frequency 2w1, 1w2.

    TED hose to stay on for approximately 3 weeks until seen by physician. May remove at night for comfort.
    4 days post-op, patient may SHOWER ONLY if wound/incision shows NO drainage.

    Medications: Lovenox 30 mg SQ BID x 14 days or Atrixia 2.5 mg once daily x 14 days.

     

    Patient instructed of Dr. Hillock’s TKA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    Change dressing with dry sterile dressing daily until drainage has stopped.
    Staple removal by doctor post-op 14 days (physician prefers to take out staples at MD visit)
    Atrixia 2.5 mg SQ once daily

    SN frequency 2w1, 1w2.

    TED hose to stay on for approximately 3 weeks until seen by physician. May remove at night for comfort.
    Patient may SHOWER ONLY if wound/incision shows NO drainage.

    Medications: Lovenox 30 mg SQ BID x 14 days or Atrixia 2.5 mg once daily x 14 days. Colace 10 mg OTC if needed

     

    none

    Patient instructed of Dr. Manning’s TKA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    NO tape to be used on skin: (1) Incision is to be left open to air 3 days post-op if no drainage is present (2) If there is drainage cover with 4×4’s and wrap with ACE bandage.
    Make sure patient gets 3-in-1 commode.
    Staple removal at MD office 2 weeks post-op.

    TED hose to stay on for approximately 3 weeks until seen by physician. May remove at night for comfort.
    4 days post-op, patient may SHOWER ONLY if wound/incision shows NO drainage.

    Medications: Lovenox 30 mg SQ BID x 14 days or Atrixia 2.5 mg once daily x 14 days.

     

    Patient instructed of Dr. Manning’s TKA protocols as follows:

    Patient to have wound/incision assessed and evaluated along with evaluation of ADL’s, medication teaching and safety evaluation
    Hospital DC instructions to be reviewed
    Change dressing with dry sterile dressing daily until drainage has stopped.
    DO NOT change steri-strips and NO betadine ointment

    Patient may SHOWER ONLY if wound/incision shows NO drainage.

    Medications: Xarelto 10 mg x 35 days (starts while patient is in hospital)

     

    none