SALDJFA

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 CASE OPENED FOR 51 YEAR OLD FEMALE REFERRED FROM ST. CHARLES WOUND CARE CLINIC FOR SKILLED NURSING ASSESSMENT, EDUCATION, AND WOUND CARE TO BILATERAL BREASTS, UNDER ARMS, LEFT AND RIGHT SIDE OF UPPER BACK, ACROSS LOWER ABDOMEN, AND BILATERAL THIGHS. PATIENT HAD A BILATERAL BREAST REDUCTION, FAT RESECTION, LIPOSUCTION OF BILATEAL FLANKS, A BILATERAL LEFT THIGH ANTERIOR SCAR REMOVAL, AND ANTERIOR ABDOMINAL WALL FLAT CLOSURE ON DECEMBER 13, 2022. PATIENT REPORTS SHE QUICKLY BEGAN DEVELOPING COMPLICATIONS WITH WOUNDS AFTER SURGERY RESULTING IN EVENTUAL DEHISCENCE OF BILATERAL THIGHS AND RIGHT BREAST. PATIENT SURGEON IS DR. THOMAS DALAGIANNIS, WHO REFERRED HER TO ST. CHARLES WOUND CARE CLINIC FOR FURTHER WOUND CARE EVALUATION AND TREATMENT. PATIENT FIRST APPOINTMENT WAS THIS MONDAY ON JANUARY 16, 2023. SHE WILL FOLLOW UP AGAIN NEXT MONDAY ON JANUARY 23, 2023. 
PATIENT LIVES WITH HER SPOUSE IN LARGE TWO STORY HOME. NO PETS. SHE HAS MINIMAL DME IN HOME BUT REPORTED SHE IS ABLE TO PARTICIPATE IN MOST ADLS WITH ASSISTANCE OF HER SPOUSE. PATIENT REPORTS GOOD FAMILY AND FRIEND SUPPORT SYSTEM IN PLACE FOR ASSISTANCE WITH ADLS, MEALS, TRANSPORTATION TO APPOINTMENTS. PATIENT STATED PRIOR TO SURGERY AND SUBSEQUENT WOUND COMPLICATIONS SHE HAD BEEN INDEPENDENT WITH COMPLETING ADLS, MEDICATION ADMINISTRATION, AND TRANSPORTATION TO APPOINTMENTS. SHE HAD BEEN USING NO ASSISTIVE DEVICES BUT NOW REQUIRES MINIMUM OF STANDBY ASSIST TO LEAVE HER HOME SAFELY. WRITER EXPLAINED TO PATIENT WHAT PT/OT SERVICES COULD PROVIDE IN THE HOME AND PATIENT DECLINED NEED FOR EVALUATION FROM EITHER THERAPY AT THIS TIME. 
HOME MEDICATIONS RECONCILED WITH PATIENT AND ALL MEDICATIONS IN THE HOME. PATIENT HAS RECENTLY STARTED AN IRON SUPPLEMENT AND MULTIVITAMIN TO ASSIST IN WOUND HEALING. SHE USES A WEEKLY PILL PLANNER TO MANAGE MEDICATIONS AND HUSBAND IS CURRENTLY SETTING UP PLANNER FOR HER WEEKLY WHILE SHE RECOVERS. PREFERRED PHARMACY IS KROGER ON NAVARRE AVE. PATIENT WILL REQUIRE SKILLED NURSING EDUCATION ON HER MEDICATION PURPOSE AND POTENTIAL SIDE EFFECTS. PATIENT IS DIABETIC, ON MULTIPLE ANTI-DIABETIC MEDICATIONS AND REPORTED LAST A1C WAS 6.6. SHE WILL REQUIRE NURSING EDUCATION ON DIABETES MANAGEMENT AND HOW UNCONTROLLED BLOOD SUGAR LEVELS CAN NEGATIVELY IMPACT HER WOUND HEALING. 
PHYSICAL ASSESSMENT COMPLETED AND DOCUMENTED IN MEDICAL RECORD. VITALS WNL AND NO ACUTE DISTRESS NOTED. PATIENT IS HIGH RISK FOR FALLS AS EVIDENCED BY UNSTEADY GAIT, MULTIPLE THROW RUGS IN THE HOME, AND POOR ENDURANCE AND WILL REQUIRE FALL PREVENTION EDUCATION. PATIENT WEARS READING GLASSES AND STATED NO ISSUES READING MEDICAL INSTRUCTIONS. PATIENT HAD DIMINISHED LUNG SOUNDS, NO COUGH NOTED. HRR. PATIENT ADMITS TO SHORTNESS OF BREATH WITH MODERATE EXERTION. PATIENT REPORTED PRIOR TO RECENT EVENTS SHE HAD BEEN A FREQUENT SWIMMER AT YMCA AND VERY ACTIVE AT HOME. SHE IS HOPEFUL TO RETURN TO BASELINE STATUS ONCE HEALED. PATIENT REPORTED NO CONCERNS RELATED TO APPETITE OR HYDRATION STATUS. PATIENT HAS BEEN INCREASING PROTEIN INTAKE TO PROMOTE WOUND HEALING WITH PROTEIN POWDER ADDED TO MEALS AND PROTEIN SHAKES. PATIENT REPORTED NO CONCERNS WITH BOWELS OR BLADDER AS WELL. LAST BM WAS TODAY AND HAS BEEN URINATING WITHOUT DIFFICULTY OR PAIN. 
SKIN ASSESSMENT COMPLETED WITH MANY SCATTERED WOUNDS NOTED TO BILATERAL BREASTS, UNDER ARMS, BACK, ABDOMEN, AND BILATERAL THIGHS. PATIENT RECEIVED NISUS WOUND VAC TODAY AT 445PM FROM CORK MEDICAL SUPPLIER. PATIENT HAS SHIPMENT OF WOUND CARE SUPPLIES THAT WERE ORDERED BY WOUND CLINIC ON MONDAY ARRIVING THIS FRIDAY. 
WOUND CARE WAS PROVIDED AS ORDERED TO WOUNDS ON BREASTS, BACK, UPPER LEFT THIGH, AND ABDOMEN WITH NO COMPLAINTS OF PAIN OR DISCOMFORT BY PATIENT. NISSUS WOUND VAC WAS APPLIED TO RIGHT THIGH WOUND AS WELL AND SET AT 125MMHG CONTINOUS WITH NO LEAKS PRESENT AT END OF VISIT. PATIENT AND SPOUSE WERE EDUCATED ON TROUBLESHOOTING VAC ALARMS AND TO REMOVE WOUND VAC AND APPLY WET TO DRY DRESSING IF LEAK IS UNABLE TO BE RESOLVED AFTER 2 HOURS. BOTH VERBALIZED UNDERSTANDING. BOTH STATE PATIENT HAS HAD WOUND VAC IN PAST THROUGH KCI FOR A PRIOR ABDOMINAL SURGERY AND HAVE UNDERSTANDING OF BASIC WOUND VAC FUNCTIONING AND TROUBLESHOOTING. WOUND MEASUREMENTS WILL NEED TO BE OBTAINED AT NEXT VISIT.
PATIENT AND SPOUSE EDUCATED ON IMPORTANCE OF HER FREQUENT REPOSITIONING AT MINIMUM EVERY 2 HOURS TO PREVENT SKIN BREAKDOWN. BOTH VERBALIZED UNDERSTANDING. 
PATIENT HANDBOOK AND OL FOLDER WERE REVIEWED AND LEFT IN HOME WITH IMPORTANT PHONE NUMBERS HIGHLIGHTED, ZONE MGMT, PEP, AND COVID PRECAUTIONS REVIEWED AS WELL. 

PATIENT IN AGREEMENT WITH CURRENT PLAN OF CARE AND NEXT PLANNED NURSING VISIT ON FRIDAY FOR WOUND ASSESSMENT, WOUND MEASUREMENTS, AND WOUND CARE. 

PATIENT AND SPOUSE EDUCATED ON WHEN TO CALL OL NURSE, SURGEON, OR WOUND CARE CLINIC VS 911 FOR EMERGENCY NEEDS. BOTH ENCOURAGED TO CALL OL FOR ANY QUESTIONS OR CONCERNS. 
CASE OPENED FOR 51 YEAR OLD FEMALE REFERRED FROM ST. CHARLES WOUND CARE CLINIC FOR SKILLED NURSING ASSESSMENT, EDUCATION, AND WOUND CARE TO BILATERAL BREASTS, UNDER ARMS, LEFT AND RIGHT SIDE OF UPPER BACK, ACROSS LOWER ABDOMEN, AND BILATERAL THIGHS. PATIENT HAD A BILATERAL BREAST REDUCTION, FAT RESECTION, LIPOSUCTION OF BILATEAL FLANKS, A BILATERAL LEFT THIGH ANTERIOR SCAR REMOVAL, AND ANTERIOR ABDOMINAL WALL FLAT CLOSURE ON DECEMBER 13, 2022. PATIENT REPORTS SHE QUICKLY BEGAN DEVELOPING COMPLICATIONS WITH WOUNDS AFTER SURGERY RESULTING IN EVENTUAL DEHISCENCE OF BILATERAL THIGHS AND RIGHT BREAST. PATIENT SURGEON IS DR. THOMAS DALAGIANNIS, WHO REFERRED HER TO ST. CHARLES WOUND CARE CLINIC FOR FURTHER WOUND CARE EVALUATION AND TREATMENT. PATIENT FIRST APPOINTMENT WAS THIS MONDAY ON JANUARY 16, 2023. SHE WILL FOLLOW UP AGAIN NEXT MONDAY ON JANUARY 23, 2023.
PATIENT LIVES WITH HER SPOUSE IN LARGE TWO STORY HOME. NO PETS. SHE HAS MINIMAL DME IN HOME BUT REPORTED SHE IS ABLE TO PARTICIPATE IN MOST ADLS WITH ASSISTANCE OF HER SPOUSE. PATIENT REPORTS GOOD FAMILY AND FRIEND SUPPORT SYSTEM IN PLACE FOR ASSISTANCE WITH ADLS, MEALS, TRANSPORTATION TO APPOINTMENTS. PATIENT STATED PRIOR TO SURGERY AND SUBSEQUENT WOUND COMPLICATIONS SHE HAD BEEN INDEPENDENT WITH COMPLETING ADLS, MEDICATION ADMINISTRATION, AND TRANSPORTATION TO APPOINTMENTS. SHE HAD BEEN USING NO ASSISTIVE DEVICES BUT NOW REQUIRES MINIMUM OF STANDBY ASSIST TO LEAVE HER HOME SAFELY. WRITER EXPLAINED TO PATIENT WHAT PT/OT SERVICES COULD PROVIDE IN THE HOME AND PATIENT DECLINED NEED FOR EVALUATION FROM EITHER THERAPY AT THIS TIME.
HOME MEDICATIONS RECONCILED WITH PATIENT AND ALL MEDICATIONS IN THE HOME. PATIENT HAS RECENTLY STARTED AN IRON SUPPLEMENT AND MULTIVITAMIN TO ASSIST IN WOUND HEALING. SHE USES A WEEKLY PILL PLANNER TO MANAGE MEDICATIONS AND HUSBAND IS CURRENTLY SETTING UP PLANNER FOR HER WEEKLY WHILE SHE RECOVERS. PREFERRED PHARMACY IS KROGER ON NAVARRE AVE. PATIENT WILL REQUIRE SKILLED NURSING EDUCATION ON HER MEDICATION PURPOSE AND POTENTIAL SIDE EFFECTS. PATIENT IS DIABETIC, ON MULTIPLE ANTI-DIABETIC MEDICATIONS AND REPORTED LAST A1C WAS 6.6. SHE WILL REQUIRE NURSING EDUCATION ON DIABETES MANAGEMENT AND HOW UNCONTROLLED BLOOD SUGAR LEVELS CAN NEGATIVELY IMPACT HER WOUND HEALING.
PHYSICAL ASSESSMENT COMPLETED AND DOCUMENTED IN MEDICAL RECORD. VITALS WNL AND NO ACUTE DISTRESS NOTED. PATIENT IS HIGH RISK FOR FALLS AS EVIDENCED BY UNSTEADY GAIT, MULTIPLE THROW RUGS IN THE HOME, AND POOR ENDURANCE AND WILL REQUIRE FALL PREVENTION EDUCATION. PATIENT WEARS READING GLASSES AND STATED NO ISSUES READING MEDICAL INSTRUCTIONS. PATIENT HAD DIMINISHED LUNG SOUNDS, NO COUGH NOTED. HRR. PATIENT ADMITS TO SHORTNESS OF BREATH WITH MODERATE EXERTION. PATIENT REPORTED PRIOR TO RECENT EVENTS SHE HAD BEEN A FREQUENT SWIMMER AT YMCA AND VERY ACTIVE AT HOME. SHE IS HOPEFUL TO RETURN TO BASELINE STATUS ONCE HEALED. PATIENT REPORTED NO CONCERNS RELATED TO APPETITE OR HYDRATION STATUS. PATIENT HAS BEEN INCREASING PROTEIN INTAKE TO PROMOTE WOUND HEALING WITH PROTEIN POWDER ADDED TO MEALS AND PROTEIN SHAKES. PATIENT REPORTED NO CONCERNS WITH BOWELS OR BLADDER AS WELL. LAST BM WAS TODAY AND HAS BEEN URINATING WITHOUT DIFFICULTY OR PAIN.
SKIN ASSESSMENT COMPLETED WITH MANY SCATTERED WOUNDS NOTED TO BILATERAL BREASTS, UNDER ARMS, BACK, ABDOMEN, AND BILATERAL THIGHS. PATIENT RECEIVED NISUS WOUND VAC TODAY AT 445PM FROM CORK MEDICAL SUPPLIER. PATIENT HAS SHIPMENT OF WOUND CARE SUPPLIES THAT WERE ORDERED BY WOUND CLINIC ON MONDAY ARRIVING THIS FRIDAY.
WOUND CARE WAS PROVIDED AS ORDERED TO WOUNDS ON BREASTS, BACK, UPPER LEFT THIGH, AND ABDOMEN WITH NO COMPLAINTS OF PAIN OR DISCOMFORT BY PATIENT. NISSUS WOUND VAC WAS APPLIED TO RIGHT THIGH WOUND AS WELL AND SET AT 125MMHG CONTINOUS WITH NO LEAKS PRESENT AT END OF VISIT. PATIENT AND SPOUSE WERE EDUCATED ON TROUBLESHOOTING VAC ALARMS AND TO REMOVE WOUND VAC AND APPLY WET TO DRY DRESSING IF LEAK IS UNABLE TO BE RESOLVED AFTER 2 HOURS. BOTH VERBALIZED UNDERSTANDING. BOTH STATE PATIENT HAS HAD WOUND VAC IN PAST THROUGH KCI FOR A PRIOR ABDOMINAL SURGERY AND HAVE UNDERSTANDING OF BASIC WOUND VAC FUNCTIONING AND TROUBLESHOOTING. WOUND MEASUREMENTS WILL NEED TO BE OBTAINED AT NEXT VISIT.
PATIENT AND SPOUSE EDUCATED ON IMPORTANCE OF HER FREQUENT REPOSITIONING AT MINIMUM EVERY 2 HOURS TO PREVENT SKIN BREAKDOWN. BOTH VERBALIZED UNDERSTANDING.
PATIENT HANDBOOK AND OL FOLDER WERE REVIEWED AND LEFT IN HOME WITH IMPORTANT PHONE NUMBERS HIGHLIGHTED, ZONE MGMT, PEP, AND COVID PRECAUTIONS REVIEWED AS WELL.

PATIENT IN AGREEMENT WITH CURRENT PLAN OF CARE AND NEXT PLANNED NURSING VISIT ON FRIDAY FOR WOUND ASSESSMENT, WOUND MEASUREMENTS, AND WOUND CARE.

PATIENT AND SPOUSE EDUCATED ON WHEN TO CALL OL NURSE, SURGEON, OR WOUND CARE CLINIC VS 911 FOR EMERGENCY NEEDS. BOTH ENCOURAGED TO CALL OL FOR ANY QUESTIONS OR CONCERNS.

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