initial visit teach and plan
[checkbox name="education" value="Provided education disease process and symptoim management |Instructed PCG to clean wound with NS/wound cleanser,apply Medhoney and cover with protective dressing 2x/wk and prn as ordered|educationprovided to PCG on fall safety and Precaution|dvised PCG to elevate and offload heels with pillows while in bed to decrease swelling and turn to sides to prevent skin breakdown|Advised med techs and caregivers to frequently offer patient fluids and ensure to prevent dehydration and constipation| Instructed PCG with Aspiration Safety|Pain management and importance of timely medication administartion|RN provided safety instructions, physical comfort, structural and emotional support during the visit. RN gave teachings regarding wound care and showed PCG the proper application of topical medication. PCG agrees with plan of care. |Fall risk education and oxygen safety education provided to son/pcg, and he verbalize understanding|SN educated the patient and caregiver on how to operate the oxygen, medication teaching done.|Advised pt to call for help when getting up and always use her walker for safety to prevent fall-verbalized understandin|v4|Reinforced safety teachings, aspiration precautions, fall preventive measures, infection control and covid 19 awareness.|teachback satisfactory|___ verblaized understanding|Advised caregiver to notify Hospice ASAP with fall incidents and any significant changes-verbalized understanding and appreciated service|Pcg was provided safety teachings, fall preventive measures, aspiration precautions, infection control and Covid 19 awareness and advised to notify Hospice team for any concern|v5|v6|v7|v8v3|v4|v5|v6|v7|Left patient safe and comfortable"] . PLAN [checkbox name="status and plan" value="MD also ordered to stop patient`s current medication for patient may not tolerate meds by mouth at this time.. Instructed daughter that patient may have liquids if patient can tolerate and swallow, to reposition regularly to prevent skin breakdown and to call hospice for any significant changes. |Foley catheter care done, emptied urine bag. |Will continue to keep patient comfortable and free of pain. Will continue to provide supportive care .|All needs attended to. No other concerns at this time|Current pain regimen with opioids and rest has been working well and pain is managed at this point. |Medication reconciliation completed. No discrepancies noted and refills ordered.|PCG is satisfied with care from HA and hospice team|ROM rendered on both upper and lower extremities, tolerated the procedures well| Patient continues with slow decline, with increasing confusion. .|engage in mindfulness/stress reduction techniques (deep breathing, meditation, guided imagery).|xxxxx|xxxxxxx.|Family and hospice team was updated regarding pt`s condition. Med rec done, no discrepancies noted. Pt and pcg has no c/o HA visits. Proper PPE`s in placed during visitation. .|Patient`s symptoms are managed by current plan of care. Medication reconciliation was done, pharmacy notified for refill needed. Medication teaching on medication compliance and symptom management are done with caregiver. PCG verbalized understanding|Covid-19 precautionary measures were observed and followed. Washing hands for at least 20 seconds with soap and water or use of at least 60% alcohol-based sanitizer, wearing a face covering/mask, and social distancing. Patient has no signs and symptoms of Covid-19. Patient did not display any signs of distress during this visit. v5|v6|v7|v8v3|v4|v5|v6|v7| Provided nursing care with respect and preserved the dignity of the individual. |Encouraged the caregiver to call the 24/7 Hopsice hotline for any issues/concerns or change of condition. "] KPS[select name="KPS" value="50%|40%|30%"] PPS[select name="PPS" value="50%|40%|30%"] FAST[select name="FAST" value="7C|7D|7E"] NYHA[select name="NYHA" value="IV|III |II"] VITALS SIGNS: BP , Pulse: -----Respiration unlabored at _____bpm, Temp ___, Oxygent saturation at in [select name="oxygen" value="room air|continous oxygen|2LPM via NC"] LMAC Recommendations of Frequency: [select name="scheduling" value="Weekly|Bi-weekly|Monthly||Next appointment to be scheduled by the guardian|The next appointment to be scheduled by the Client"]. The next appointment is scheduled for [date name="variable_1" default="today"]
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