Client Patient

Location:

Richmond, TX

Posted:

October 01, 2024

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HOSPICE NOTES

GLAUCOMA….

Sn will Stress the importance of meticulous compliance with prescribed drug therapy.

Sn will Provide sedation, and analgesics as necessary. Acute glaucoma attack is associated with sudden pain, which can precipitate anxiety and agitation, further elevating IOP.

Sn will allow expression of feelings about loss and the possibility of a loss of vision.

Sn will Implement measures to assist patients to manage visual limitations such as reducing clutter, arranging furniture out of travel path; turning heads to view subjects; correcting for dim light and problems of night vision.

Sn will demonstrate administration of eye drops (counting drops, adhering to the schedule, not missing doses). Controls IOP, preventing further loss of vision.

Sn will Promote a calm and soothing environment by ensuring adequate lighting, and minimizing noise and distractions in the environment.

The CG/ client will participate in the therapeutic regimen.

The CG/client will maintain the current visual field/acuity without further loss.

The CG/ client will appear relaxed and report anxiety is reduced to a manageable level.

The CG/ client will verbalize understanding of the condition, prognosis, and treatment.

The CG/ client will identify the relationship between signs/symptoms to the disease process.

The CG/client will verbalize understanding of treatment needs.

The CG/ client will correctly perform the necessary procedures and explain the reasons for the actions.

COPD…..

Sn educated patient on how to appropriately administer bronchodilators and corticosteroids and become alert for potential side effects.

Sn educated patient on how to control coughing directly/indirectly which is more effective and reduces fatigue associated with undirected forceful coughing.

Sn educated patient how to improve breathing pattern with Inspiratory muscle training to improve breathing pattern.

Sn educated patient diaphragmatic breathing to reduce respiratory rate, increase alveolar ventilation, and sometimes helps expel as much air as possible during expiration.

Sn educated patient Pursed lip breathing to help slow expiration, prevents collapse of small airways, and control the rate and depth of respiration.

Sn educated patient how to manage daily activities.it must be paced throughout the day and support devices can be also used to decrease energy expenditure.

Exercise training. Exercise training can help strengthen muscles of the upper and lower extremities and improve exercise tolerance and endurance.

Walking aids. Use of walking aids may be recommended to improve activity levels and ambulation.

To monitor and manage potential complications:

Monitor cognitive changes. The nurse should monitor for cognitive changes such as personality and behavior changes and memory impairment.

Monitor pulse oximetry values. Pulse oximetry values are used to assess the patient’s need for oxygen and administer supplemental oxygen as prescribed.

Prevent infection. The nurse should encourage the patient to be immunized against influenza and S. pneumonia because the patient is prone to respiratory infection.

Patient will verbalize factors that contribute to worsening COPD

Patient will demonstrate appropriate use of inhaler and oxygen

Patient will verbalize symptoms that warrant assessment and intervention

Patient will verbalize how to conserve energy by doing the task that requires more energy first when energized

HYPOTHYROIDISM

The client will maintain a stable weight and takes in necessary nutrients.

The client and family members will verbalize correct information about hypothyroidism and taking thyroid hormone replacement.

The client will identify the basis of fatigue and individual areas of control.

The client will verbalize a reduction of fatigue and increased ability to complete desired activities.

Teach the expected benefits and possible side effects.

The client should report symptoms such as chest pain/palpitations; these happen due to increased metabolic and oxygen consumption.

Emphasized the importance of rest periods.

Avoid undue fatigue; As the euthyroid state is achieved, the activity level will eventually increase.

Encourage the client to follow appointments for blood workups (T3, T4, and TSH levels).

These levels help determine the effectiveness of pharmacotherapy

Describe the signs and symptoms of over- and under-dosage of the medications.

This will serve as a check for the client to determine if the therapeutic levels are met.

Instruct the client to take the dose in the morning to avoid insomnia.

Thyroid hormone should be taken on a regular basis to achieve a hormone balance.

2.2. Instruct the client to take the medication on an empty stomach.

The client is initially given a small dose that gradually increases until a euthyroid state is achieved. When the thyroid hormone level increases, the client experiences insomnia and weight loss.

SOB…DYPNEA…Sn educated patient and family about dyspnea management, including breathing techniques, medication administration, and symptom recognition.

Sn will Provide written instructions and resources for ongoing self-management and support.

Sn also talked to patient about ways to minimize exposure to triggers, such as allergens or pollutants, by ensuring good indoor air quality and avoiding smoking or secondhand smoke. Sn, patient and caregiver talked about how to create a quiet and peaceful environment to reduce stress and promote relaxation. Sn encouraged patient to prioritize activities and engage in energy-conserving techniques to prevent fatigue and reduce dyspnea on exertion.

Patient will demonstrate an increase in activity levels.

Patient will be able to engage in activities without experiencing fatigue.

Patient will actively participate in activities, both necessary and desired.

Patient will verbalize feeling less tired with more energy.

OBESITY… Patient will lose significant number of pounds to achieve desired body weight.

Patient will learn to accept themselves despite weight loss or gain.

Patient will accept responsibility for making changes to improve self-image.

Patient will identify times, settings, and emotions that induce overeating.

Patient will verbalize healthier food choices in place of processed foods.

Patient will reduce daily calorie intake by 20%.

Educate why exercise is important. The nurse should first instruct the patient on how exercise affects their cholesterol. Patients often know that a poor diet is a cause of high cholesterol but may not know that a sedentary lifestyle is also a contributor.

Start slow. Educate the patient that the recommended amount of exercise is 150 minutes per week.

Determine exercise and dietary habits.

Assess the patient’s current activity level and usual dietary intake as well as their schedule, living environment, and access to resources to develop interventions.

Assess for pain or conditions that limit movement.

Chronic pain conditions, surgeries, multiple sclerosis, and impaired mobility can make it unsafe to participate in certain activities. The nurse can help the patient identify exercises they can safely participate in.

SOB

Patient will deny shortness of breath.

Patient will maintain an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation.

Patient will have ABG results within normal limits.

Patient will incorporate breathing techniques to improve breathing pattern.

Patient demonstrates the ability to complete ADLs without dyspnea.

ANXIETY….Patient will be able to acknowledge and discuss fears and concerns

Patient will be able to verbalize feelings of anxiety and present ideas of how to handle those feelings

Patient will be able to develop and demonstrate problem-solving techniques

Patient will be able to identify appropriate resources

Patient’s vital signs will remain or return to stable baseline state

Patient will be able to maintain regular sleep routine

Educate patient on new coping mechanisms or previously used ones that were effective for the patient.

This will allow the patient to build confidence in oneself in being able to handle these difficult situations and will gain the individual independence once home

Encourage the patient to engage in regular daily exercise and activity programs.

Educate patient that Irrational thoughts, fears, and strong negative feelings towards the pain may worsen anxiety leading to panic.

Educate the patient about the precipitating factors of chest pain.

Educate patient on resources the patient can use at home, in the future, along with a plan to follow for breakthrough episodes of anxiety. This will allow the patient more independence at home and comfort in having already developed a plan to follow if another episode of anxiety occurs.

HYPERLIPIDEMIA Sn instructed patient on managing hyperlipidemia means controlling cholesterol and triglycerides. Read food labels and choose foods with low cholesterol and saturated trans-fat. For people who would benefit from lowering their cholesterol, the American Heart Association recommends aiming for a dietary pattern that limits saturated fat to 5 to 6 percent of daily calories and reduces the percent of calories from trans fat.

SN instructed about managing Hyperlipidemia such as: Limit your intake of red meat and dairy products made with whole milk to reduce your saturated and trans fat. Choose skim milk, lowfat or fat - free dairy products. Limit fried food, and use healthy oils in cooking, such as vegetable oil.

Patient will participate in 30 minutes of exercise 3-4 days per week.

Patient will choose activities that do not cause pain but improve strength.

Patient will experience an improvement in HDL cholesterol levels as evidenced by lab work.

Patient will not miss any doses of statin medication for 2 weeks.

Patient will verbalize one reason to decrease cholesterol.

PAIN Encourage the patient/CG to carry out a light range of motion exercises, activity as tolerated.

Gradually increase activity with active range-of-motion exercises in bed, increasing to sitting and then standing.

RN assess for signs of intolerance such as pallor, nausea, lack of consciousness, and dizziness.

Coordinate rest periods before straining activities such as eating, bathing, and ambulating.

Educated patient/caregiver on the importance of pre-medicating patient prior painful procedures to prevent pain symptoms

Managing symptom and medication regime.

Maintains optimal gas exchange.

Maintains unlabored respirations, oxygen saturation within normal range, and baseline HR.

Decreased signs of respiratory distress.

Compliance to medication and other therapeutic interventions.

SOB symptoms managed.

Patient will exhibit a decrease in pain-related behaviors.

Patient/caregiver will maintain compliance with prescribed pain medication regimen, including adhering to prescription instructions, administering medications, monitoring for efficacy, and avoiding medication errors.

SAMPLE PROGRESS NOTE

Mary Smith is a 45 y/o white female admitted to the Behavioral Health Unit for complaints of “people talking in her head.” Ms. Smith has a history of Bipolar Disorder and Paranoid Schizophrenia. Although there has been no significant sign of decline since admission, Ms. Smith has shown little sign of positive improvement since the last assessment. Vital signs upon assessment are as follows: B/P 130/78, Apical Pulse 72, Resp. 18, Temp. 98.1, Weight 187 lbs. Ms. Smith is non-aggressive with a flat affect. Although she attends group sessions and activities, her participation is minimal to none. She shows little interest in people or activities in her surroundings. She appears depressed, speaking with a slow, monotone voice, walking slowly, and showing little interest in self-care, as evidenced by disheveled clothing and unbrushed hair. Ms. Smith reports feeling sad and angry because the people in her head will not stop talking, but she denies suicidal ideations or intentions. She reports the voices are especially loud when she tries to sleep unless she takes "that new sleep medicine." She states if she does not take her sleep medication, the “people talk to my head all night.” She was recently prescribed Ambien CR, as needed at bedtime, to help with sleeplessness and appears more rested on the mornings following its use. She reports having a dry mouth and was instructed this is a side effect of Ambien. I encouraged adequate fluid intake and routine oral hygiene to help with dry mouth symptoms. No other changes or concerns were noted. Notified Dr. Hughes, the attending psychiatrist, of Ms. Smith's continued reports of hearing voices and my observation that she may also be experiencing visual hallucinations. Awaiting response at this time.-Jason Holyfield, RN

Mark Snow is a 70 y/o black male admitted to home health services for wound care of previously untreated decubitus ulcer. The patient is alert and oriented and denies complaints of pain or new concerns. Vital Signs: B/P 128/80, P 72, R 16, Temp 98.6. The Stage 2 decubitus ulcer, with partial thickness and located in the lower sacral region, measured 5 cm x 4 cm upon admission. Today, the wound measures 4 cm x 2.5 cm. The wound shows an improved presence of red granulation tissue and minimal drainage. Instructed Mr. Snow's wife on how to perform dressing changes, as she will change his dressings between nurse visits and prn. Mrs. Snow performed wound care by return demonstration, cleansing the wound with normal saline, patting it dry, and applying a silver-impregnated foam dressing, as per orders. Educated the patient and caregiver on the importance of keeping the wound clean and dry and ensuring frequent position changes to reduce pressure on the affected area. Also discussed signs and symptoms of infection, including foul odor, increased pain, tenderness, redness, or purulent draining, and instructed to notify the attending physician or home health if these symptoms occur. Both Mr. Snow and Mrs. Snow voice their understanding. There are no other changes in patient status or orders at this time. Allison Wilks, RN

EXAMPLE #4: Palliative Care Patient

Date and Time of Assessment: Oct. 1, 2023 @ 1245

Patient Name: Herman Jones

Patient ID: 123456

Nurse: Margo Littleton, RN

Mr. Jones is an 81 y/o white male admitted to hospice for palliative care services related to diagnoses of Chronic Obstructive Pulmonary Disease, Stage IV Lung Cancer, and Congestive Heart Failure. The patient is currently living in his home with his son and daughter rotating weekly stays with him. Vital signs today: B/P 150/88, P 74, R 26, T 98.2. The patient is on 02 per nasal cannula at 2L/min continuous; no skin irritation or breakdown was noted on ears or nares from the nasal cannula. Bilateral wheezes were noted on auscultation, and patient reports a continued productive cough with thick yellowish-brown sputum. 3+ pitting edema noted in bilateral lower extremities. The patient is prescribed Lasix 40 mg. each morning but states he forgot to take it the last two days. Instructed patient and caregiver on the importance of medication compliance to prevent exacerbation of symptoms. Mr. Jones states he is “tired of living like this.” Denies thoughts of suicide but states he is "ready to go." Notified attending physician of depression symptoms and notified bereavement coordinator to request a bereavement visit be scheduled. The bereavement coordinator states she will see Mr. Jones tomorrow morning to offer support. Educated caregiver on signs and symptoms of worsening disease processes and symptoms of worsening depression. Also, I provided the patient and caregiver with contact information for the on-call nurse for after-hours concerns. Increasing CNA visits to five times weekly for added support. I will follow up with the bereavement coordinator and nursing assistant after their visits tomorrow to decide if nurse visits should also be increased. No other concerns/problems have been noted at this time Margo Littleton, RN

EXAMPLE #5: Asthmatic Patient

Date & Time of Assessment: 10/04/23 @ 1935

Patient Name: Jones, Audra

Patient ID: 654321

Nurse: Alton Vickery, RN

Ms. Jones is a 28 y/o white female presenting to the emergency department with complaints of shortness of breath lasting longer than two hours. She has a history of asthma, which is usually well-controlled. She is alert and oriented, denies pain but does express some chest discomfort when trying to take a deep breath. Skin is W&D, good turgor, no compromised skin integrity noted. Vital Signs: B/P 140/90, P 84, R 24 shallow, T 99.1. Shortness of breath and bilateral wheezes were also noted. Pt. Reports productive cough with thick white sputum. Spirometry Level: 76%; Pt. Diagnosed by Dr. Chan with asthma exacerbation and bronchitis. Administered Albuterol 1/25 mg/3ml via nebulizer, as ordered by MD. After 10 minutes, pt. reassessed, and breathing is less labored; pt. seems more relaxed. Ms. Jones stated she let her asthma medication run out and forgot to call her primary care physician for a refill. Sent prescription refill for Albuterol inhaler 90 mcg per actuation to pt's primary pharmacy, per order, and educated pt. on importance of medication compliance and keeping follow-up appointments with PCP. Pt. Voiced understanding. Discharged to home with an education packet on the prevention of asthma exacerbation and scheduled an appointment with her primary care physician for follow-up A. Vickery, RN

FALL

Ensure that wheels are locked on bed. Keep dim light in room at night. Check for medication side effects and consult with physician/pharmacist. Assist with ADLs as indicated for safety. Educate the patient to use assistive devices such as wear glasses and hearing aids or to use walking aids as this will help with balancing when he walks. Sn encouraged patient to sit up and dangle first before standing up from bed.

Patient reported pain using a standardized pain scale, established a self-identified pain goal, and pain goal of no pain not met yet.

no falls reported during this visit. Patient said he tried using Cain to walk to prevent fall but stopped because he doesn't want to depend on it. Sn encouraged patient to always put safety into consideration.

Patient will have no falls.

Patient will have no injury from falls.

Patient/caregiver will verbalize fall safety instructions.

Patient will remain free of falls

Patient will demonstrate a safe environment free from potential hazards

Patient will verbalize understanding of risk factors for falls

PAIN Patient reported pain using a standardized pain scale, established a self-identified pain goal, and pain goal of no pain not met yet.

PAIN…..Patient will in finding comfortable positions that alleviate pressure on painful areas. Use pillows, cushions, or positioning aids as necessary to promote comfort.

Patient will collaborate with physical therapists to develop tailored therapeutic exercise programs that improve strength, flexibility, and mobility, while taking into account the patient’s pain tolerance.

Patient will meditation, engage in deep breathing exercises, or yoga, to reduce stress, anxiety, and muscle tension associated with generalized body pain.

Patient will get good sleep hygiene practices, such as maintaining a consistent sleep schedule, creating a comfortable sleep environment, and avoiding stimulating activities before bedtime.

Patient will verbalize understanding of energy conservation measures.

Educated patient and/or caregiver(s) on aspiration precautions.

Encouraging the patient to drink plenty of fluids, including water and other clear liquids, to promote hydration and help soften stool.

Encouraging the patient to consume a high-fiber diet, including fruits, vegetables, and whole grains, to promote regular bowel movements

Sn encourage will have all ADL, safety, and activity needs met. Caregiver will verbalize understanding of the expected decline in cognitive status related to disease progression.

SN to fill pill box and check pill box at SN visits to ensure adherence to medication regimen.

Sn will educate patient/caregiver about myths and misconceptions about pain medications, including pseudoallergies, addiction, and pseudoaddiction.

Sn will educate patient/caregiver to store medications in original container or in pill box .

Patient will verbalize a significant reduction of pain as evidenced by stable vital signs and absence of restlessness and guarding behavior.

Sn will discuss the patient’s/caregiver’s fears of undertreated pain, medication side effects, and addiction.

Sn will educate patient/caregiver on the importance of prompt reporting of unrelieved pain.

Sn will patient/caregiver on the importance of pre-medicating patient prior painful procedures to prevent pain symptoms.

Sn will educate patient/caregiver on verbal and non-verbal pain cues.