Piedra Filosofal Del Poc

ORDERS FOR DISCIPLINE AND TREATMENTS SN FREQUENCY : ___________ SN ORDERS : SKILLED OBSERVATION/ASSESSMENT, ASSESS VITAL SIGNS AND SIGN/SYMPTOMS OF COMPLICATIONS: _________ SYSTEM. ASSESS PATIENT’S RESPONSE TO AND COMPLIANCE WITH PLAN OF CARE ON EVERY VISIT. INSTRUCT /EVALUATE UNDERSTANDING OF : DISEASE PROCESS, MEDICATION REGIMEN, ( ACTION/SIDE EFFECTS), DETECTING COMPLICATIONS, DIET/NUTRITIONAL STATUS, SAFETY PRECAUTIONS AND EMERGENCY MEASURES. ( INSERT ORDERS HERE) REPORT ANY SIGNIFICANT CHANGES IN PATIENT’S CONDITION TO PHYSICIAN. TEACHING AND TRAINING: DISEASE PROCESS, MEDICATION REGIMEN, SKIN CARE/DIET/NUTRITION/HYDRATION, SYMPTOM CONTROL MEASURES, SAFETY, PREVENTION OF INJURIES AND EMERGENCY PLANS. TYPE OF SKILL SERVICE REQUIRED: ASSESSMENT/OBSERVATION: (list systems to be reported, s/s and complications to report) MANAGEMENT AND EVALUATION. PAIN STATEMENTS : SN TO ASSESS PAIN LEVEL (TYPE/FREQUENCY/INTENSITY/IIRADIATION) INSTRUCT ON PAIN CONTROL MEASURES , ASSESS FOR PATIENT RELIEF. FALL STATEMENTS : SN TO ASSSESS PATIENT FOR FALL RISK AND REASSESS AS NECESSARY WITHIN 30 DAYS. SN TO INSTRUCT PATIENT /CAREGIVER ON SAFETY MEASURES, SAFE USE OF ASSISTIVE DEVICE ( WALKER, CANE), AND SAFE AMBULATION. WOUND CARE: SN TO ASSESS INTEGUMENTARY STATUS. SN TO PERFORM WOUND CARE (FREQ) TO WOUND/ULCER IN (LOCATION) WHICH MEASURES AS FOLLOWS: L: CM X W: CM X D: CM, WITH __ AMOUNT OF __ DRAINAGE, __ ODOR, __ EDEMA, __ UNDERMINING/TUNNELING, PERIWOUND IS INTACT AND WOUND BED IS PINK WITH GRANULATION TISSUE. SN TO PROVIDE THE FOLLOWING WOUND CARE: " " FOLLOWING ASEPTIC TECHNIQUES AND UNIVERSAL PRECAUTIONS. SN TO ASSESS WOUND FOR SIGN/SYMPTOMS OF HEALING/INFECTION/COMPLICATIONS, AND REPORT WOUND STATUS/PROGRESS TO PHYSICIAN __________________

SN TO MEASURE WOUND EVERY WEEK, ASSESS DRAINAGE ON EACH VISIT FOR AMOUNT, COLOR, ODOR, AND CONSISTENCY. INSTRUCT PATIENT IN WOUND CARE PROCEDURE, WAYS TO PROMOTE WOUND HEALING, SIGNS /SYMPTOMS OF HEALING/COMPLICATIONS TO REPORT TO PHYSICIAN. PATIENT IS UNABLE TO PERFORM OWN WOUND CARE DUE TO: _______________________________________________________________________ ___________________________________________________________________ NO CARE GIVER AVAILABLE TO ASSIST THE PATIENT WITH WOUND CARE. INJCETABLE MEDICATION: SN TO ADMINISTER ( MEDICATION, DOSE, ROUTE , FREQUENCY, DURATION) FOLLOWING ASEPTIC TECHNIQUES, UNIVERSAL PRECAUTIONS, SITE ROTATION METHOD, AND PROPER DISPOSAL OF SHARPS. PATIENT IS UNABLE TO ADMINISTER OWN ____ ( ROUTE) INJECTION AS ORDERED BY PHYSICIAN, DUE TO : ( REASON) ________. IV THERAPY : SN ADMINSITERED ______ ( MEDICATION, DOSAGE IN ML, FREQUENCY, RUN OVER ________ ( HOUR/MIN.) VIA __________ ( CATHETER TYPE AND LOCATION) VIA ( GRAVITY OR IV PUMP ( TYPE). ( ADD FLSUH PROTOCOL) SN TO FLUSH FIRST WITH _____ ML OF NSS /HEPARIN, THEN ADMINISTER ( MEDICATION) AND THEN FLUSH AFTER ADMINISTRATION OF MEDICATION WITH __ ML OF __________ . SN CHANGE IV SITE DRESSING EVERY ________ HOURS. ( ADD LABORATORY IF APPLICABLE) PEG TUBE CARE SN TO PERFORM PEG SITE CARE AND PEG FEEDINGS OF ____ VIA ___ FLUSHING WITH _____CC OF WATER AFTER EACH FEEDING, AND WITH ______CC OF WATER AFTER MEDICATION ADMINISTRATION. SN TO TEACH AND ASSESS PATIENT / CAREGIVER ABILITY TO PERFORM PEG FEEDING AND PEG SITE CARE INCLUDING PREPARATION AND STORAGE OF FEEDING, EQUIPMENT CARE, FLUSHING TECHNIQUE, FLOW RATE CALCULATION, ASSESSMENT OF PEG SITE FOR SIGNS OF INFECTION, PRN VISITS FOR CLOG, LEAK OF MALFUNCTION.

FOLEY CATHETER SN TO PERFORM FOLEY MAINTENANCE (FREQ) UTIIZING ____FR/FOLEY WITH ____CC/BALLO ___ PRN VISITS FOR CLOG, LEAK, OR ACCIDENTAL REMOVAL. LAST FOLEY CHANGE PERFORMED ON (DATE). SN TO IRRIGATE FOLEY WITH ___CC OF ____ (FREQ) AND PRN FOR _____. SN TO TEACH AND ASSESS PATIENT / CAREGIVER ABILITY TO CARE FOR INDWELLING CATHETER. *FOR INFUSIONS/IVS* SN TO ADMINISTER (MED) VIA (CATH) (FREQ), AS PER PHYSICIAN'S ORDERS, SEE BOX 10. SN TO FLUSH (CATH) W/(NSS) PRIOR TO ADMI BLOOD PRESSURE SKILLED OBSERVATION/EVALUATION, ASSESS VITAL SIGNS AND SYMPTOMS OF COMPLICATIONS, WITH SPECIAL ATTENTION TO CARDIOVASCULAR SYSTEM. SN TO ASSESS CARDIOVASCULAR STATUS, MONITOR BLOOD PRESSURE ON EACH NURSING VISIT, AND MANTAIN RECORD OF THE SAME, CALL PHYSICIAN IF BLOOD PRESSURE GREATER THAN 140/90 MMHG OR LOWER THAN 100/60 MMHG. SN TO ASSESS FOR SIGNS/SYMPTOMS OF UNCONTROLLED HYPERTENSION: TINNITUS, DIZZINESS, OR NASAL BLEEDING. SN TO ASSESS FOR IRREGULAR HR, PALPITATIONS, TACHYCARDIA OR BRADYCARDIA, FLUID RETENTION OR EDEMA. SN TO INSTRUCT PATIENT ON DISEASE PROCESS/COMPLICATIONS, PROGRESS OF DISEASE, DIET AND COMPLIANCE WITH NUTRITIONAL REQUIREMENT, NEW MEDICATIONS, SIDE/ADVERSE EFFECTS TO REPORT TO PHYSICIAN, WHEN TO DISCONTINUE MEDICATION, AND ADEQUATE USE, SAFETY/EMERGENCY MANGEMENT, AND FOLLOW UP WITH PHYSICIAN. SN TO REPORT ANY SIGNIFICANT FINDINGS TO NURSE/AGENCY. PT FREQUENCY : RPT TO PERFORM INITIAL EVALUATION WITH FOLLOW UP VISITS FOR PHYSICAL THERAPY SERVICES. RPT TO ASSESS/EVALUATE MUSCLE STRENGH, ROM, AMBULATION, BED MOBILITY, TRANSFER ABILITY, COORDINATION, BALANCE, ENDURANCE, DISEASE PROCESS, PAIN, HOME SAFETY AND ADL'S. RPT TO PROVIDE PATIENT WITH HOME EXERCISE PROGRAM. : RPT TO SUPERVISE PTA/AIDE VISITS EVERY 14 DAYS. ( PUT SPECIFIC ORDERS/GOALS) AIDE FREQUENCY: ( SPEFIC ORDERS AND FREQUENCY : DAILY OR PRN)

GOALS SN GOALS: 1) PATIENT WILL VERBALIZE UNDERSTANDING OF DISEASE PROCESS AND CURRENT HEALTH STATUS. 2) PATIENT WILL VERBALIZE UNDERSTANDING OF THERAPEUTIC DIET 3) PATIENT WILL VERBALIZE UNDERSTANDING OF S/S TO REPORT TO PHYSICIAN. 4) PATIENT WILL RETURN TO OPTIMUM ENDOCRINE STATUS W/O COMPLICATIONS OR FURTHER PROGRESSION OF DISEASE PROCESS. ( BE SPECIFIC WITH OASIS GOALS) PT GOALS: RPT GOALS: 1) PATIENT WILL DEMONSTRATE ABILITY TO FOLLOW HEP. 2) PATIENT WILL ATTAIN MAXIMUM JOINT MOBILITY AND MUSCLE STRENGH. 3) PATIENT WILL BE INDEPENDENT OR BE ABLE TO PARTICIPATE IN ACTIVITIES OF DAILY LIVING. 4) PATIENT WILL BE COMFORTABLE WITH IN HOME SETTINGS. 5) OPTIMUM FUNCTION WILL BE ATTAINED AND MAINTAINED. AIDE GOALS: AIDE GOAL: AIDE WILL PROVIDE PERSONAL CARE IN ORDER TO MAINTAIN AN OPTIMAL LEVEL OF PATIENT'S PERSONAL HYGIENE. THE PATIENT WILL REMAIN SAFE, CLEAN AND COMFORTABLE WITH EFFECTIVE CARE; PERSONAL CARE NEEDS WILL BE MET. WOUND CARE GOALS SN GOAL: ONGOING PATIENT AND CAREGIVER WILL DEMONSTRATE COMPLIANCE WITH DIABETIC CARE AND INSTRUCTIONS; WILL IDENTIFY S/S OF HYPO/HYPERGLYCEMIA AND MEASURES TO PREVENT DIABETIC COMPLICATIONS. PATIENT WILL LEARN GOOD SKIN CARE AND PREVENT ANY SKIN BREAKDOWN. PATIENT WILL DEMONSTRATE INCREASED HEALING PROCESS WITHOUT ANY S/S OF INFECTION OR OTHER COMPLICATIONS.