SN 2Wk5, 1Wk4 and 3 PRN visit for rechecking of pt's BS if pt's BS is

greater than or less than the set parameters with manifestations of

hypo/hyperglycemia.
Assess VS and all body system, knowledge of Disease Process and its
associated care and treatment, medication regimen knowledge, and s/s
complications necessitating medical attention.
Notify MD of SBP greater than 140 or less than 90; DBP greater than 90 or
less than 60.
Notify MD of Pulse greater than 100 or less than 60.
Notify MD of Respirations greater than 30 or less than 15.
Notify MD of Temperature greater than 100.4 or less than 95.
Glucometer testing to be performed by pcg/pt once daily.
Notify MD of BS greater than 250mg/dl or less than 70mg/dl
Weigh patient every visit.
Notify O2 saturation if below 90% with manifestation of SOB/DOB to MD
Notify MD of weight gain greater than 5 lbs in 1 week.
RESPIRATORY MANAGEMENT
Instruct Pt./Pcg regarding disease process related to Pulmonary HTN
Assess respiratory status, rate and rhythm, breath sounds, lung expansion
Assess for breathing pattern
Assess abnormal breath sounds and s/sx of respiratory distress
Assess sputum production and character, frequency and amount
Perform pulse oximetry
Instruct patient regarding, optimal functioning, and huff techniques, use of
pillow or hand splints when coughing and use of abdominal muscles for
more forceful cough
Important of ambulation and frequent position changes
Provide O2 administration at 2 L min via NC
Instruct in use, safety, maintenance, precautions storage and care of O2
therapy
Instruct in energy conservation, use of accessory muscle, pursed lip
breathing, coughing and deep breathing exercises
Instruct on proper positioning with proper body alignment for optimal
respiratory excursion/ facilitate ventilation/perfusion matching
Instruct to monitor local air quality reports for potential allergens /
pollutants that may increase breathing problems
CARDIOVASCULAR MANAGEMENT
Instruct Pt./Pcg regarding disease process related to CHF
Assessment of cardiovascular status every visit to include pulse, changes
in rate and rhythm, pulse deficits, orthostatic hypotension, edema,
dyspnea with exertion, chest pain
Instruct the patient proper technique for checking blood pressure and
pulse keeping a record of readings to show MD, and notify MD if results are
greater than identified parameters
Instruct the Pt./Pcg dietary restrictions to include Low Na, Low fat, Low
cholesterol

Instruct on measures to recognize cardiac dysfunction and relieve

complication
Instruct on energy conservation techniques to include rest periods in
activities to limit fatigue
Instruct in use of Nitroglycerin to relieve chest pain
Weigh patient every visit
Fluid restriction of 1.5L/day
Notify physician of weight variation of 5 lbs a week
Instruct on methods to detect / alleviate fluid retention
Instruct on lifestyle modifications such as regular physical activity and
reduced sodium intake.
Assist Patient to identify modifiable risk factors that increases blood
pressure
Instruct on the importance of adhering to treatment regimen and keeping
follow up appointments
Instruct patients in establishing a daily routine for taking medications, to
keep a record of drugs, report for any adverse reactions
Instruct on stress reduction activities and energy reservation, rest,
avoidance of stress tension (physical and mental rest)
Assess elimination pattern to determine risk for constipation and straining
that may trigger blood pressure to increase
Determine patients specific questions related to health maintenance
Discuss non compliance with instructions or programs to determine
rationale for failure
EDEMA MANAGEMENT
Inspect skin daily, observe for signs of breakdown
Provide daily skin care: wash with mild soap, rinse, and pat dry; ensure
that skin is thoroughly dried; lubricate skin with lanolin lotion
Report breakdown to nurse immediately
Avoid adhesive tapes directly on skin
Avoid use of tight constricting socks or hose; reposition extremities
frequently. Do not cross legs.
Use cotton or woolen socks that are proper length and size
Wear properly fitting shoes when out of bed; avoid getting barefoot.
Take diuretic (fluid pill) as ordered by doctor. A diuretic is a medicine that
increases urine output to decrease edema by removing excess fluid from
the body.
Take diuretic early in the morning. Taking late afternoon or night often
disturbs sleep.
Keep record of intake and output. You may lose large amounts of fluid even
after a single dose of fluid medication.
Weigh daily to be sure edema is being controlled. Weight loss should not
be more than 1-2lbs per day.
Report being unable to urinate, weakness or muscle cramps.
Check feet, legs, hands, face, stomach and tail bone area for swelling each
day.
Avoid salt and foods high in sodium content and follow diet ordered by MD.
Elevate feet above level of heart.

GENITOURINARY MANAGEMENT
Instruct Pt./Pcg regarding disease process related to Chronic renal
insufficiency
Instruct regarding the importance of adequate hydration, drink 1.5L fluids /
day and s/sx of dehydration
Assess patients recognition of need to urinate
Visual examination of urine to determine Color, Clarity, Presence of
sediments and Hematuria
Instruct the Pt./Pcg s/sx of UTI to include changes in urine output, color
quality, odor and temperature 2 degrees higher than the patients baseline
of 100.4 F
ENDOCRINE/DIABETES MANAGEMENT
Instruct Pt./Pcg regarding disease process related to Diabetes
Blood glucose testing
Instruct Pt./Pcg. in s/sx of hypo/hyperglycemia
Instruct in NCS diet, exercise and activity level / modification
Instruct Pt./Pcg in use, care and calibration of glucometer
Instruct patient in rationale of keeping a written record of blood sugar
results to show to MD for treatment reference
Instruct Pt./Pcg to check blood sugar daily
Instruct Pt./Pcg preparation and administration of insulin including rotation
of injection sites, type of insulin including peak times
Instruct insulin needs / dosage in the event of illness or surgery
Instruct in proper disposal of lancets use for blood sugar testing and Insulin
syringes use for injection
Instruct in diabetic neuropathy, importance of foot care including
monitoring for the presence of skin lesions on the lower extremities, proper
footwear and effects of temperature changes
Instruct in diabetic retinopathy, importance of regular eye examination,
proper eye wear
Instruct in changes to healing process because of diabetes
SAFETY/FALL MANAGEMENT
Instruct Pt./Pcg.on safety measures to prevent fall / injury
Implement and instruct medication regimen, including dosage, side effects,
name, route, frequency, desired action and adverse reaction
Assess medication compliance / medication set-up
Safe ambulation / bed / chair transfer
Instruct Pt./Pcg. on how to access emergency aid
HHA ORDERS
HHA FREQ: 2wk2, 1wk7
Assesses, monitors and supervises patients to ensure their health, safety
and welfare
Assists patients with activities of daily living skills:
Basic personal hygiene, care and grooming, including bathing, hair care,
dressing
Bladder and/or bowel requirements or problems, including helping
individuals to and from the bathroom or with bedpan routines

Performs household services and both heavy and light home cleaning tasks
Assists with preparing a shopping list, performing grocery shopping and
preparing meals, runs miscellaneous errands

SN GOALS:
Patient will have improved pulmonary status as evidenced by decreased
SOB, clear lung sounds, improved O2 exchange, improved
Stable respiratory status and achieves even unlabored respirations 16-28
within 2-3 weeks and treatment plan
The Pt./Pcg will be able to verbalize understanding of signs of increased
respiratory problems to report to MD to within 4 weeks
The Pt./Pcg will be able to demonstrate use, safety and care of oxygen
equipment within 3 weeks
Stable cardiovascular throughout treatment plan as evidenced by BP within
90/60 mmHg and 160/90 mmHg, PR 60-100 / min, and no s/sx of
Hypertension, hypotension or heart failure exacerbation
The Pt./Pcg will be able to to identify s/sx of cardiac distress to report to
the MD and when to seek care at an acute care facility within 3 weeks
The Pt./Pcg will verbalize and demonstrate techniques to minimize edema
within 3 weeks with compliance to medications and dietary restrictions
The patient will be able to verbalize and demonstrate understanding and
compliance with dietary restrictions and identify appropriate food choices
with the use of dietary diary, and demonstrate adherence to order within 3
weeks
The Pt./Pcg will be able to verbalize the administration of Nitroglycerin to
relieve chest pain
Patient demonstrate adaptive coping behaviors by identifying risk factors
that elevate blood pressure within certification period
Patient maintain adequate cardiac output and hemodynamic stability
The Pt./Pcg will be able to verbalize and demonstrate adequate hydration
as evidenced by good skin turgor / urine is clear, yellow within 4 weeks
Stable GU status throughout treatment plan
The Pt./Pcg will verbalize symptoms of hypo / hyperglycemia
The Pt./Pcg will verbalize and demonstrate compliance with 1.5L/day fluid
restriction, low sodium, low cholesterol and no concentrated sugar diet and
exercise as evidenced by blood sugar results within 70mg/dl to 250mg/dl
within 4 week
Pt demonstrates compliance to medications and NCS diet

The Pt./Pcg will demonstrate competency in the use, care and calibration
of glucometer by independently performing treating and recording blood
sugar results with 100% accuracy within 3 weeks
The Pt./Pcg will verbalize and demonstrate preparation and administration
of insulin, rotation of injection sites with 100% accuracy within 3 weeks
The Pt./Pcg will verbalize and demonstrate proper disposal of lancets for
blood sugar testing
The Pt./Pcg will verbalize and demonstrate proper disposal of insulin
syringes with 100% accuracy within 4 weeks
The Pt./Pcg will verbalize and demonstrate good foot / skin care as
evidenced by no skin breakdown during certification period
The Pt./Pcg will verbalize disease process of diabetes including adverse
s/sx of impending problems to report to the physician within 5 weeks
Will increase safe, functional ability by demonstrating ability to (transfer)
ambulate within 4 weeks
Will verbalized understanding and demonstrate compliance with safety, fall
precautions within 4 weeks
Will have no evidence of (fall) (injury) (skin breakdown) throughout
treatment plan
Takes all medication with respect to timing with 1-2 weeks and throughout
treatment plan
HHA GOAL:
The patients hygiene and personal care needs will be met this certification
period with the assistance of home health aide

PAIN MANAGEMENT
Assess pain status/characteristics with an accurate use of pain to include:
quality, severity level, location, onset, duration, precipitating/aggravating,
causative and relieving factors
Observe/monitor/Assess s/sx associated with pain includes significant
changes in v/s, color and moisture of skin, restlessness and ability to focus
Assess patients knowledge of or preference for the array of pain- relief
strategies available
Evaluate patients expectation for relief of pain and medications or
therapeutics aimed at abolishing or relieving pain.
Assess pt/pcg willingness or ability to explore a range of techniques aimed
at controlling pain
Monitor/assess for changes in general condition that may herald need for
change in pain relief method
Pt/pcg eliminate additional stressors or sources of discomfort whenever
possible
Instruct rest periods to facilitate comfort sleep and relaxation and
intervention to mitigate pain
Assist pt/pcg in determining appropriate pain relief method on
pharmacological (with doctors orders/approval) and non pharmacological
INTEGUMENTARY/WOUND CARE

Assess general condition of skin; specifically over bony prominences

Assess patients awareness of the sensation of pressure
Assess patients mobility and nutritional status
Instruct / perform skin care, measures to prevent skin breakdown,
measures to decrease pressure and improve circulation
Assessment includes decubitus / pressure, stasis, diabetes ulcers and
surgical incisions
Assess/Stage wound every visit and measure every week
SN to provide wound care on SN visits as follows: clean the wound with
irrigation solution ensuring that the old cream was removed, pat dried with
non sterile gauze, Apply Silvadene cream to the affected area and covered
it with non adhesive gauze, wrapped with conforming gauze and secured
with micropore tape.
Notify MD if wound(s) are not responding to current treatment
Instruct the Pt./Pcg on how to perform wound care, wound care to be
perform by Pcg on non SN visits
Instruct in proper administration, action, dosage, frequency and side
effects of topical medications.
Instruct the Pt./Pcg infection control measures and universal precautions
such as proper hand washing and proper and proper disposal of wound
care materials
Instruct the Pt./Pcg regarding s/s of infection to include redness and
inflammation, foul odor, purulent discharge and fever, position to relieve
pressure, and proper nutrition to promote healing
CARDIOVASCULAR/HYPERTENSION MANAGEMENT
Instruct Pt./Pcg regarding disease process related to HYPERTENSION
Assessment of cardiovascular status every visit to include pulse, changes
in rate and rhythm, pulse deficits, orthostatic hypotension, edema,
dyspnea with exertion, chest pain
Instruct the patient proper technique for checking blood pressure and
pulse keeping a record of readings to show MD, and notify MD if results are
greater than identified parameters
Instruct the Pt./Pcg dietary restrictions to include Low Na, Low fat, Low
cholesterol
Instruct on measures to recognize cardiac dysfunction and relieve
complication
Instruct on energy conservation techniques to include rest periods in
activities to limit fatigue
Assess / instruct compliance with cardiac medications and Pt./Pcg
knowledge of action, dosage, frequency of administration and side effects
Instruct on lifestyle modifications such as regular physical activity and
reduced sodium intake.
Assist Patient to identify modifiable risk factors that increases blood
pressure
Instruct on the importance of adhering to treatment regimen and keeping
follow up appointments
Instruct patients in establishing a daily routine for taking medications, to
keep a record of drugs, report for any adverse reactions

Instruct on stress reduction activities and energy reservation, rest,

avoidance of stress tension (physical and mental rest)
Assess elimination pattern to determine risk for constipation and straining
that may trigger blood pressure to increase
Determine patients specific questions related to health maintenance
Discuss non compliance with instructions or programs to determine
rationale for failure
ENDOCRINE/DIABETES MANAGEMENT
Instruct Pt./Pcg regarding disease process related to DIABETES
Blood glucose testing
Instruct Pt./Pcg on medication regimen with oral hypoglycemic agents
Instruct Pt./Pcg. in s/sx of hypo/hyperglycemia
Instruct in NCS diet, exercise and activity level / modification
Instruct Pt./Pcg in use, care and calibration of glucometer
Instruct patient in rationale of keeping a written record of blood sugar
results to show to MD for treatment reference
Instruct Pt./Pcg to check blood sugar.
Instruct in diabetic neuropathy, importance of foot care including
monitoring for the presence of skin lesions on the lower extremities, proper
footwear and effects of temperature changes
Instruct in diabetic retinopathy, importance of regular eye examination,
proper eye wear
Instruct in changes to healing process because of diabetes.
FALL/SAFETY MANAGEMENT
Instruct Pt./Pcg.on safety measures to prevent fall / injury
Implement and instruct medication regimen, including dosage, side effects,
name, route, frequency, desired action and adverse reaction
Assess medication compliance / medication set-up
Safe ambulation / bed / chair transfer
Instruct Pt./Pcg. on how to access emergency aid
IV THERAPY MANAGAMENT
The SN will administer (Meropenem 1gm daily for 5 days and Vancomycin
1gm for 5 doses every 72 hours via Peripheral line
Assess line for patency, leakage s/sx of infiltration, phlebitis, infection and
adverse reaction to meds.
Flush line with 5 ml of sterile normal saline soluition prior to and after the
administration of medication
Instruct patient / caregiver regarding the administration of medication
using aseptic technique and s/sx of infection at IV site including redness
and inflammation, warm to touch, discharge and fever to report to MD
Instruct in infection control measures and universal precautions such as:
Proper hand washing, Disposal of materials.
Change injection cap every visit and PRN
States pain at tolerable level of 3 and below on the scale of 0-10 within 2-3
weeks and throughout treatment plan

Pt will demonstrate accurate use of pain scale and verbalize level of pain
Pt./Pcg identify, verbalize understanding on factors relieving aggravating
pain and effectiveness of pain management
Pt./Pcg demonstrate intervention to mitigate pain / control measures,
relaxation techniques
Pt./Pcg will demonstrate ways in assessing skin, performing skin care,
measures to prevent skin breakdown, decrease pressure and improve
circulation
The patients wound(s) will heal 10-25% 1-2 weeks, 26-50% 2-4 weeks, 5175% 4-6 weeks, 76-100% 6-8 weeks as evidenced with reduction of
redness, wound size, depth and no drainage
The patients wound will completely healed within 9 weeks
Pt./Pcg will verbalize / demonstrate proper / competence in performing
wound care within 2 weeks
The wound(s) will be free from infection as evidenced by no redness and
swelling, no drainage, no odor, no deviation of temperature greater than 2
degress above the patients baseline of 100.4 F while agency is providing
care
The patient will be able to verbalize action, dosage, frequency, side effects
and demonstrate proper administration of topical medication
The patient pain will be controlled with non-pharmacological measures
between 2-5 on 1-10 pain scale
Optimal nutrition throughout treatment plan
Stable cardiovascular throughout treatment plan as evidenced by BP within
90/60 mmHg and 160/90 mmHg, PR 60-110 / min, and no s/sx of
Hypertension, hypotension or heart failure exacerbation
The Pt./Pcg will be able to to identify s/sx of cardiac distress to report to
the MD and when to seek care at an acute care facility within 3 weeks
The Pt./Pcg will demonstrate proper technique for monitoring and
recording pulse and blood pressure results within 3 weeks
The patient will be able to verbalize and demonstrate understanding and
compliance with dietary restrictions and identify appropriate food choices
with the use of dietary diary, and demonstrate adherence to order within 3
weeks
The patient will be able to verbalize the actions, frequency, dosage and
side effects of oral medications
Patient demonstrate adaptive coping behaviors by identifying risk factors
that elevate blood pressure within certification period
Patient maintain adequate cardiac output and hemodynamic stability
The Pt./Pcg will verbalize signs/symptoms of hypo / hyperglycemia
The Pt./Pcg will verbalize and demonstrate compliance with low sodium,
low cholesterol and no concentrated sugar diet and exercise as evidenced
by blood sugar results within 70 mg/dl to 250mg/dl within 3 weeks
Pt demonstrates compliance to medications and No Concentrated Sugar
diet
The Pt./Pcg will demonstrate competency in the use, care and calibration
of glucometer by independently performing treating and recording blood
sugar results with 100% accuracy within 3 weeks
The Pt./Pcg will verbalize and demonstrate good foot / skin care as
evidenced by no skin breakdown during certification period

The Pt./Pcg will verbalize disease process of diabetes including adverse

s/sx of impending problems to report to the physician within 3 weeks
Will increase safe, functional ability by demonstrating ability to (transfer)
ambulate within 2 weeks
Will verbalized understanding and demonstrate compliance with safety, fall
precautions within 2 weeks
Will have no evidence of (fall) (injury) (skin breakdown) throughout
treatment plan
Takes all medication with respect to timing with 1-2 weeks and throughout
treatment plan
The patients IV insertion site will remain free of infection as evidenced by
no signs of redness, swelling, discharge and the patients temperature will
not increase greater than 2 degrees above the patients baseline temp of
100.4 degrees while the patient is receiving IV therapy
Aseptic technique
Universal infection control measures
Patient will complete infusion and tolerate procedure without any
complications

RESPIRATORY/OXYGEN THERAPY
Assess respiratory status, rate and rhythm, breath sounds, lung expansion
Assess for breathing pattern
Assess abnormal breath sounds and s/sx of respiratory distress
Assess sputum production and character, frequency and amount
Perform pulse oximetry
Provide O2 administration at 2 L min; via nasal cannula
Instruct in use, safety, maintenance, precautions storage and care of O2
therapy
Instruct in emergency plan for continued use of O2 in the event of power
shortage
Administer / instruct Nebulizer Rx / assess compliance
Instruct in use, care and safety of SVN treatment machine
Perform/Instruct Suctioning technique
Instruct on proper positioning with proper body alignment for optimal
respiratory excursion/ facilitate ventilation/perfusion matching
Instruct to monitor local air quality reports for potential allergens /
pollutants that may increase breathing problems
Attach suction catheter to connecting tubing. Remove oxygen mask from
patient if present. Nasal cannula or prongs may be left in place while
performing this type of suctioning.
Insert catheter into patients mouth. With suction applied, move the
catheter around the mouth, including the pharynx and the gum line until
secretions are cleared. If the catheter does not have a suction control to
apply intermittent suction, take care not to traumatize oral mucosal
surfaces with continuous suctioning.

Instruct to keep the pt. clean and dry by always checking the diaper, to
avoid any complications related to incontinence.
CARDIOVASCULAR/HYPERTENSION
Instruct Pt./Pcg regarding disease process related to HYPERTENSION
Assessment of cardiovascular status every visit to include pulse, changes
in rate and rhythm, pulse deficits, orthostatic hypotension, edema,
dyspnea with exertion, chest pain
Instruct the patient proper technique for checking blood pressure and
pulse keeping a record of readings to show MD, and notify MD if results are
greater than identified parameters
Instruct the Pt./Pcg dietary restrictions to include Low Na, Low fat, Low
cholesterol
Instruct on measures to recognize cardiac dysfunction and relieve
complication
Instruct on energy conservation techniques to include rest periods in
activities to limit fatigue
Assess / instruct compliance with cardiac medications and Pt./Pcg
knowledge of action, dosage, frequency of administration and side effects
Instruct on lifestyle modifications such as regular physical activity and
reduced sodium intake.
Assist Patient to identify modifiable risk factors that increases blood
pressure
Instruct on the importance of adhering to treatment regimen and keeping
follow up appointments
Instruct patients in establishing a daily routine for taking medications, to
keep a record of drugs, report for any adverse reactions
Instruct on stress reduction activities and energy reservation, rest,
avoidance of stress tension (physical and mental rest)
Assess elimination pattern to determine risk for constipation and straining
that may trigger blood pressure to increase
Determine patients specific questions related to health maintenance
Discuss non compliance with instructions or programs to determine
rationale for failure
GASTROINTESTINAL/PEG CARE
SN to assess bowel sounds every visit and identify normal functioning
pattern for patient
Instruct measuring / recording intake / dietary intake and output, to
promote oral intake and measures to recognize dysfunction and relieve
complications
Instruct Pt./Pcg in relief of: nausea / vomiting/ gastric distress / other with
the use of prescribed medication
Instruct to notify SN / MD if no bowel movements for a period greater than
3 days associated with abdominal
Regular PEG tube
Instruct Perform GT feeding and care
Cleanse GT site with NS, apply slit gauze and secure with tape
Head of bed elevated, check tube placement and check for residual

Hold GT if residual is greater than 60ml

Flush with 30 cc before and after feeding
Assess tolerance of enteral feeding
Implement and instruct medication regimen, including dosage, side effects,
name, route, frequency, desired action and adverse reaction
Assess medication compliance / medication set-up
INTEGUMENTARY
Assess general condition of skin; specifically over bony prominences
Assess patients awareness of the sensation of pressure
Assess environmental moisture, surface that patients spends majority of
time, amount of shear and friction on patients skin
Instruct/perform strict turning schedules
Encourage implementation of pressure-relieving devices commensurate
with degree of risk for skin impairment
Instruct on having a strict turning schedule to as part of the pressure relief
measures to avoid bed sores.
Instruct to maintain limbs in functional alignment
Instruct / perform skin care, measures to prevent skin breakdown,
measures to decrease pressure and improve circulation
Assessment includes decubitus / pressure, stasis, diabetes ulcers and
surgical incisions
SAFETY/FALL INTERVENTION
Safe ambulation / bed / chair transfer
Instruct Pt./Pcg. on how to access emergency aid
Assesses, monitors and supervises patients to ensure their health, safety
and welfare
Assists patients with activities of daily living skills:
Basic personal hygiene, care and grooming, including bathing, hair care,
dressing
Bladder and/or bowel requirements or problems, including helping
individuals to and from the bathroom or with bedpan routines
Performs household services and both heavy and light home cleaning tasks
Assists with preparing a shopping list, performing grocery shopping and
preparing meals, runs miscellaneous errands
GOALS:
-Pt./Pcg will demonstrate ways in assessing skin, performing skin care,
measures to prevent skin breakdown, decrease pressure and improve
circulation throughout treatment plan
-Optimal nutrition throughout treatment plan
-Patient will have improved pulmonary status as evidenced by decreased
SOB, clear lung sounds, improved O2 exchange, improved color throughout
treatment plan
-The Pt./Pcg will be able to verbalize understanding of signs of increased
respiratory problems to report to MD to within 2 weeks
-The Pt./Pcg will be able to demonstrate use, safety and care of oxygen
equipment within 2 weeks

-The Pt./Pcg will be able to demonstrate use, safety and care of SVN
machine within 2 weeks
-The Pt./Pcg will be able to verbalize and demonstrate the action, dosage,
frequency of administration and side effects of respiratory medications
throughout treatment plan
-Stable cardiovascular throughout treatment plan as evidenced by BP
within 90/60 mmHg and 160/90 mmHg, PR 60-110 / min, and no s/sx of
Hypertension, hypotension or heart failure exacerbation
-The Pt./Pcg will be able to to identify s/sx of cardiac distress to report to
the MD and when to seek care at an acute care facility throughout
treatment plan
-The Pt./Pcg will demonstrate proper technique for monitoring and
recording pulse and blood pressure results within 1 week and throughout
treatment plan
-The pcg will be able to verbalize and demonstrate understanding and
compliance with dietary restrictions and identify appropriate food choices
with the use of dietary diary, and demonstrate adherence to order within 1
weeks and throughout treatment plan
-Patient maintain adequate cardiac output and hemodynamic stability
throughout treatment plan
-Demonstrate knowledge regarding tube feedings, administration of
medication via PEG care and management throughout treatment plan
-Verbalized knowledge regarding prevention of constipation, understanding
of medications / treatments to relieve constipation within 2 weeks
-Pt will demonstrate measures to promote adequate hydration, nutrition, to
prevent / resolve diarrhea / constipation, to relieve gastric discomfort
-PEG tube site will remain intent with no s/sx of infection throughout
treatment plan
-Pt will be able to tolerate feedings without complications throughout
treatment plan
-PCG Will verbalized understanding and demonstrate compliance with
safety, fall precautions throughout treatment plan
-Will have no evidence of fall,injury,skin breakdown throughout treatment
plan
-Takes all medication with respect to timing with 1-2 weeks and throughout
treatment plan
-The patients hygiene and personal care needs will be met this certification
period with the assistance of home health aide
PT GOALS:
-Will show active movement on left LE and UE within 6 weeks
- Be able to perform proper self assisted ROM ex within 3-4 weeks.
- Pt's affected extremity will show minimal synergistic actions to avoid
typical hemiplegic posture by the end of the episode.
- Pcg/relatives will be able to perform proper assistance in transfer and be
compliant in home instructions including positioning of affected extremities
in 4 week time.
- Will initiate sitting at the edge of the bed with fair balance and tolerance
as a preparation for wheelchair transfers within 6 week time.

RENAL / GENITOURINARY
SN to change Foley catheter # 16 French 10ml sterile water balloon, every
4weeks and 3 PRN Visit for blockage, leakage of inadvertent removal,
entrapped tubing and emergency removal
Instruct Pcg in catheter care to include emergency measures when
catheter is removed and positioning of the drainage bag
Instruct Pcg of s/sx of complications to include occlusion of catheter,
increased odor, urinary retention, bladder spasm, potential for urine
leakage after insertion of catheter or entrapped tubing, and emergency
removal
Instruct regarding the importance of adequate hydration, drink 8-10glasses
fluids / day and monitoring s/sx of dehydration
Visual examination of urine to determine Color, Clarity, Presence of
sediments and Hematuria
Instruct the Pcg s/sx of infection to include changes in urine output, color
quality, odor and temperature
Instruct regarding care of patient to include frequent changes of bedding,
pads, skin care
Instruct in infection control measures and universal precautions
INTEGUMENTARY/WOUND CARE
Assess general condition of skin; specifically over bony prominences
Assess patients awareness of the sensation of pressure
Assess patients mobility and nutritional status
Assess environmental moisture, surface that patients spends majority of
time, amount of shear and friction on patients skin
Encourage implementation of pressure-relieving devices commensurate
with degree of risk for skin impairment
Instruct to maintain limbs in functional alignment
Instruct / perform skin care, measures to prevent skin breakdown,
measures to decrease pressure and improve circulation
As ordered wound assessment/care/teachings/instructiions to be provided
by PT.
SN to coordinate to PT in the status of the wound
SN/PT to Notify MD if wound(s) are not responding to current treatment
being provided by PT
Instruct the Pt./Pcg infection control measures and universal precautions
such as proper hand washing and proper and proper disposal of wound
care materials
Instruct the Pt./Pcg regarding s/s of infection to include redness and
inflammation, foul odor, purulent discharge and fever, position to relieve
pressure, proper nutrition to promote healing.
DIGESTIVE / COLOSTOMY
SN to assess bowel sounds every visit and identify normal functioning
pattern for patient

Instruct measuring / recording intake / dietary intake and output, to

promote oral intake and measures to recognize dysfunction and relieve
complications
Instruct regarding COLOSTOMY CARE
SKIN CARE:
Look at the skin around your stoma each time you change your pouch.
Your stoma should be pink or red and moist. You may have a small amount
of bleeding when you clean your stoma. This is normal. Your stoma will get
smaller and become its normal size in about 8 weeks.
Make sure the skin barrier opening fits well: The skin barrier is the part of
the pouch that sticks to the skin of your abdomen. It should be no more
than ? of an inch larger than stoma. If the opening is too large, bowel
movement can leak onto skin and cause irritation. Measure the size of
stoma with the guide that comes with colostomy supplies. Make sure to cut
the skin barrier smaller as your stoma gets smaller.
Soothe irritated skin: Ifskin is red, it may mean that the skin barrier was
on too long. It is important to find the cause of skin irritation. Ask if need
help finding the cause of skin irritation.
CHANGING POUCH:
How you change pouch depends on the type pts have. Pts will be given
specific instructions on how to change colostomy pouch. The following is
general information about how to change pouch:
Ask how often to change colostomy pouch: The type of pouch affects the
amount of time it can be worn. The kind and amount of bowel movement
also affects how long the pouch stays on.
Remove the pouch: Gently remove the pouch by pushing the skin down
and away from the adhesive skin barrier with one hand. With the other
hand, pull the pouch up and away from the stoma.
Gently clean the skin around stoma: Use mild soap and water. Do not use
soaps that have oil or perfumes. Pat skin dry.
Use a pouch with the right size opening: Use a pouch that has an opening
that is ? of an inch larger than stoma.
Use skin products to help reduce irritation: These products can help
protect skin and keep it dry.
Use slight pressure to place clean pouch: Center the pouch over the
stoma and press it firmly into place on clean, dry skin. It may be helpful to
hold hand over the new pouch for 30 seconds. The warmth of hand can
help stick the adhesive skin barrier into place.
Dispose of the used pouch correctly: If the pouch is disposable, place the
old pouch in another plastic bag and throw it in the trash. If you use a
reusable pouch, ask how to clean it.
EMPTYING POUCH:
Empty the pouch when it is ? to full: Do not wait until the pouch is
completely full. This could put pressure on the seal and cause it to leak or
spill.
Hold the pouch up by the bottom end: If the pouch has a clamp system,
remove the clamp. You may need to roll the end back to keep it from
getting soiled.

Drain the pouch: Place toilet paper into the toilet before emptying the
pouch to reduce splash back. Drain the pouch by squeezing the contents
into the toilet.
Clean the end of the pouch: Use toilet paper or a moist paper towel. May
also rinse the pouch but it is not necessary. Keep the end of the pouch
clean.
Close the end of the pouch: Unroll the end of the pouch. Replace the
clamp or close the end of the pouch according to your primary healthcare
provider's instructions.
IRRIGATING COLOSTOMY:
Primary healthcare provider or gastroenterologist will tell if you can irrigate
colostomy.
Below are some general steps for irrigation:
Gather your supplies: Need plastic irrigating container with a long tube
and a cone to put water into colostomy. Need an irrigation sleeve that will
direct the output into the toilet.Need an adjustable belt to attach the
irrigation sleeve and a tail closure for the end of the sleeve.
Choose the same time every day to irrigate: This will help decrease
problems with your colostomy.
Know how much liquid to use: Fill the irrigating container with about 16 to
50 ounces (500 to 1500 mL) of lukewarm water. The water should not be
cold or hot. Ask how much water you will need to irrigate. Hang the
irrigation container so that it is level with your shoulder. Sit up straight on
the toilet or on a chair next to the toilet.
Attach the irrigation sleeve to your stoma: Take the adjustable belt and
attach it to the irrigation sleeve. Place the belt around your waist and place
the sleeve over your stoma. Place the end of the irrigation sleeve into the
toilet bowl.
Release air bubbles from the tubing: Release the clamp and allow a small
amount of water to flow into the sleeve. Clamp the tubing again.
Moisten the end of the cone: Use water or a water-soluble lubricant.
Place the tip of the cone 3 inches into your stoma: Make sure the fit is
snug, and do not force the cone. Release the clamp on the tubing again
and slowly allow the water to flow into the stoma This should take about 5
to 10 minutes. Keep the cone in place for another 10 seconds.
Remove the cone: Allow the output to drain into the irrigation sleeve for
about 10 to 15 minutes. Dry the end of the irrigation sleeve. Clip the
bottom of the sleeve to the top with a clasp or close the end of the sleeve
with the tail closure. It may take 30 to 45 minutes to drain. You may move
around during this time. Empty the output from the sleeve into the toilet.
Clean the area around the stoma with mild soap and water and pat dry.
Foods to eat with a colostomy:
Eat a variety of healthy foods: Healthy foods include fruits, vegetables,
whole-grain breads, low-fat dairy products, lean meats, and fish. Do not eat
foods that give you cramps or diarrhea.
Limit foods that may cause gas and odor: These include vegetables such
as broccoli, cabbage, and cauliflower. Beans, eggs, and fish may also cause
gas and odor. Eat slowly and do not use a straw to drink liquids. Yogurt,
buttermilk, and fresh parsley may help control odor and gas.

Drink liquids as directed: Ask how much liquid to drink each day and
which liquids are best for you. This may help reduce constipation.
Follow up with primary healthcare provider or gastroenterologist as
directed:
Need to return to have stoma and colostomy checked. Bring equipment to
appointments and any time pts have to go to the hospital. Write down
questions so pts can remember to ask them during your visits.
FALL PREVENTION / SAFETY / MEDICATION INTERVENTION
Instruct Pt./Pcg.on safety measures to prevent fall/injury
Implement and instruct medication regimen, including dosage, side effects,
name, route, frequency, desired action and adverse reaction
Assess medication compliance / medication set-up
Safe/bed/chair transfer
Instruct Pt./Pcg. on how to access emergency aid
SN GOALS:
Pt./Pcg will demonstrate ways in assessing skin, performing skin care,
measures to prevent skin breakdown, decrease pressure and improve
circulation
care
Optimal nutrition throughout treatment plan
Will verbalize understanding and demonstrate compliance with safety, fall
precautions throughout entire treatment plan.
Will have no evidence of fall, injury and skin breakdown throughout
treatment plan.
The Pt./Pcg will verbalize understanding of signs and symptoms of urinary
tract infection and prevention of infection within throughout the
certification period.
Pt./Pcg will verbalize management of incontinence without skin breakdown
throughout the certification period.
Pt./Pcg demonstrate ostomy care properly within certification period
Pt will demonstrate measures to promote adequate hydration, nutrition, to
prevent / resolve diarrhea / constipation, to relieve gastric discomfort
throughout treatment plan
Pt./Pcg. will verbalize understanding of / demonstrate proper colostomy
care throughout treatment plan
Colostomy site will remain patent without any s/sx of infection throughout
treatment plan
The patient will remain free of urinary tract infection within certification
period
The Pcg will verbalize and demonstrate to SN knowledge of catheter care,
management, troubleshooting maintaining patent catheter and proper
disposal of catheter supply throughout the certification period.
The patient catheter will remain patent during certification period
Stable GU status throughout treatment plan

NEUROLOGICAL
Assess Neurological status R/T diagnosis of CVA
Assess patient to identify presence of:
headache
difficulty with speech
inability to read or write
alteration in memory
altered consciousness
confusion or change in thinking
disorientation
decrease in sensation, tingling or pain
motor weakness or decreased strength
decreased sense of smell or taste
change in vision or diplopia
difficulty with swallowing
decreased hearing
difficulty with swallowing
altered gait or balance
dizziness
tremors, twitches or increased tone
Assess/Monitor s/sx and manifestations of increase intracranial pressure
including headache, vomiting without nausea, ocular palsies, altered level
of consciousness, back pain and papilledema
Instruct stress management skills, relaxation techniques, positive coping
skills
Assess s/sx of anxiety, depression ineffective coping
Instruct Pcg/family to maintain reality-oriented relationship/environment
with the patient
CARDIO/HYPERTENSION MANAGEMENT
Instruct Pt./Pcg regarding disease process related to HTN
Assessment of cardiovascular status every visit to include pulse, changes
in rate and rhythm, pulse deficits, orthostatic hypotension, edema,
dyspnea with exertion, chest pain
Instruct the patient proper technique for checking blood pressure and
pulse keeping a record of readings to show MD, and notify MD if results are
greater than identified parameters
Instruct the Pt./Pcg dietary restrictions to include Low Na, Low fat, Low
cholesterol
Instruct on energy conservation techniques to include rest periods in
activities to limit fatigue
Instruct on lifestyle modifications such as regular physical activity and
reduced sodium intake.
Assist Patient to identify modifiable risk factors that increases blood
pressure
Instruct on the importance of adhering to treatment regimen and keeping
follow up appointments
Instruct patients in establishing a daily routine for taking medications, to
keep a record of drugs, report for any adverse reactions

ENDOCRINE/DIABETIC
Instruct Pt./Pcg regarding disease process related to DM
Instruct Pt./Pcg. in s/sx of hypo/hyperglycemia
Instruct in NCS diet, exercise and activity level / modification
Instruct Pt./Pcg in use, care and calibration of glucometer
Instruct patient in rationale of keeping a written record of blood sugar
results to show to MD for treatment reference
Instruct Pt./Pcg to check blood sugar every before breakfast and before
dinner
SN to check pts BS during visit if pt did not check his BS prior to visit
Instruct in proper disposal of lancets use for blood sugar testing
Instruct in diabetic neuropathy, importance of foot care including
monitoring for the presence of skin lesions on the lower extremities, proper
footwear and effects of temperature changes
Instruct in diabetic retinopathy, importance of regular eye examination,
proper eye wear
Instruct in changes to healing process because of diabetes
INTEGUMENTARY/SKIN CARE/PRESSURE ULCER PREVENTION
Assess general condition of skin; specifically over bony prominences
Assess patients awareness of the sensation of pressure
Assess patients mobility and nutritional status
Assess environmental moisture, surface that patients spends majority of
time, amount of shear and friction on patients skin
Instruct/perform strict turning schedules (applicable to
Bedridden/restricted to bed)
Instruct to maintain limbs in functional alignment
Instruct / perform skin care, measures to prevent skin breakdown,
measures to decrease pressure and improve circulation
DIGESTIVE / GASTROINTESTINAL / NUTRITIONAL
SN to assess bowel sounds every visit and identify normal functioning
pattern for patient
Instruct to notify SN / MD if no bowel movements for a period greater than
3 days
Parenteral Nutrition and the care / use of equipment to include:
Regular PEG tube
Instruct Perform PEG feeding and care:
Cleanse PEG site with NS, apply slit gauze and secure with tape
Head of bed elevated, check tube placement and check for residual
Hold PEG if residual is greater than 60ml
FALL PREVENTION/SAFETY MEASURES
Instruct Pt./Pcg.on safety measures to prevent fall / injury
Implement and instruct medication regimen, including dosage, side effects,
name, route, frequency, desired action and adverse reaction
Assess medication compliance / medication set-up
Safe ambulation / bed / chair transfer
Instruct Pt./Pcg. on how to access emergency aid

SN GOALS
Pt./Pcg can identify s/sx of impaired neurologic status / neurologic deficit
throughout treatment plan
No Manifestations of increase ICP throughout treatment plan
Pt will demonstrate stable mental status and adaptive coping mechanisms
indicative of psychosocial adjustment throughout treatment plan
Stable cardiovascular throughout treatment plan as evidenced by BP within
90/60 mmHg and 160/90 mmHg, PR 60-100/ min, and no s/sx of:
Hypertension exacerbation
The Pt./Pcg will be able to identify s/sx of cardiac distress to report to the
MD and when to seek care at an acute care facility within certification
period.
The patient will be able to verbalize and demonstrate, with the use of
dietary diary, adherence to order client within certification period.
Will be able to identify risk factors that elevate blood pressure within the
certification period
Patient identify appropriate food choices, expresses more energy within
certification period
Patient demonstrate adaptive coping behaviors within certification period
The Pt./Pcg will verbalize understanding of symptoms of hypo /
hyperglycemia throughout treatment plan
The Pt./Pcg will verbalize and demonstrate compliance with NCS diet and
exercise as evidenced by blood sugar results within 70-250mg/dl within
certification period
The Pt./Pcg will demonstrate competency in the use, care and calibration
of glucometer by independently performing treating and recording blood
sugar results with 100% accuracy within 2 weeks and throughout
treatment plan
The Pt./Pcg will verbalize and demonstrate proper disposal of Lancets for
blood sugar testing and insulin syring used throughout treatment plan
The Pt./Pcg will verbalize and demonstrate good foot / skin care as
evidenced by no skin breakdown during certification period
Pt./Pcg will demonstrate ways in assessing skin, performing skin care,
measures to prevent skin breakdown, decrease pressure and improve
circulation
Optimal nutrition throughout treatment plan
The patient/pcg will be able to verbalize and demonstrate understanding
and compliance with dietary restrictions and identify appropriate food
choices with the use of dietary diary, and demonstrate adherence to order
within 9 weeks
Demonstrate knowledge regarding tube feedings, administration of
medication via PEG, care and management within certification period
G tube site will remain intent with no s/sx of infection throughout
treatment plan
Pt will be able to tolerate feedings without complications throughout
treatment plan
Pts G tube will be free from infection and remain intact within the
certification period

Will verbalize understanding and demonstrate compliance with safety, fall

precautions throughout entire treatment plan.
Will have no evidence of fall, injury and skin breakdown throughout
treatment plan.

SN ORDERS
FREQ: 2wk2, 1wk7
Assess VS and all body system, knowledge of Disease Process and its
associated care and treatment, medication regimen knowledge, and s/s
complications necessitating medical attention.
SN to assess vital signs every visit.
Notify MD of SBP greater than 160 or less than 90 DBP greater than 90 or
less than 60.
Notify MD of Pulse greater than 100 or less than 60
Notify MD of Respirations greater than 20 or less than 12
Notify MD of Temperature greater than 100.4 or less than 95
NEUROLOGICAL
Assess Neurological status R/T diagnosis of CVA
Assess/Monitor s/sx and manifestations of increase intracranial pressure
including headache, vomiting without nausea, ocular palsies, altered level
of consciousness, back pain and papilledema
Instruct stress management skills, relaxation techniques, positive coping
skills
Assess s/sx of anxiety, depression ineffective coping
Instruct Pcg/family to maintain reality-oriented relationship/environment
with the patient
REINFORCEMENT OF NEUROLOGICAL/DEMENTIA MANAGEMENT
Reinforce Pcg to Provide pts activity which is a cornerstone of care such as
physical activities, arts and crafts (do not use toxic substances), mental
stimulation (no strict or reinforced rules,use discretion), discussion groups,
assist with objects to see/touch, reminiscence use objects to
show/touch/smell to assist memory, home making chores, music,
relaxation, outings (generally to quiet places, no crowds, planned ahead,
extra staffing), drama appropriate, special programs
Reinforced guidelines to assure adequate nutrition such as make eating
easy, serve food that the patient like, try finger foods, check for physical
comfort, give clear and safe instructions, plan ahead when eating outside

Reinforced tips to provide better nights sleep by eliminating alcohol and

avoiding caffeine, prevention of daytime napping, make sure pt is
comfortable, create a familiar sleeping area, help patient relax before
bedtime, make environment safe in case the pts get up
Make bathing and personal care easier, monitor grooming needs, make
grooming safe and comfortable, help pt dress appropriately, treat pt with
respect, and simplify grooming tasks when possible
CARDIOVASCULAR/HYPERTENSION MANAGEMENT
Continue assessment of cardiovascular status every visit to include Pulse
deficits,Changes in pulse rate / rhythm, Orthostatic hypotension, Breath
sounds, Edema, Dyspnea with exertion and Chest pain
Reinforce/monitor compliance in dietary restrictions to include Low Na,
Low fat and Low cholesterol
Reinforce importance of adhering to treatment regimen and keeping follow
up appointments
INTEGUMENTARY/SKIN CARE/PRESSURE ULCER PREVENTION
Continue assessment of general condition of skin, patients awareness of
the sensation of pressure, mobility and nutritional status, environmental
moisture, surface that patients spends majority of time, amount of shear
and friction on patients skin
Monitor/evaluate compliance of Pcg on infection control measures and
universal precautions such as proper hand washing and proper and proper
disposal of wound care materials
RENAL/GENITOURINARY MANAGEMENT
Instruct the Pt./Pcg to measure and record the patients intake and output
daily. Notify SN if urine output is less than 30ml/hr
Visual examination of urine to determine Color, Clarity, Presence of
sediments and Hematuria
FALL PREVENTION/SAFETY MEASURES
Reinforce/monitor compliance on safety measures to prevent fall / injury
and medication error.
PT ORDERS
FREQ: 1wk1, 2wk8
Strengthening exercises using Therabond on both LE x 10 reps x 2-3 sets
or as Pt tolerance.
Mobility exercises such as sit <-> stand with 1 minimal assistance to SBA.
Standing balance with wt. shifting, heel raise may add up mini-squats for
LE strengthening
Gait training such as walking on level surface SBA as to Pt tolerance.
SN begins in 1Wk9 and 3 PRN visit for rechecking of pt's BS if pt's BS is
greater than or less than the set paramaters with manifestations of
hypo/hyperglycemia and reinforcement of health teachings.

Assess VS and all body system, knowledge of Disease Process and its
associated care and treatment, medication regimen knowledge, and s/s
complications necessitating medical attention.
SN to assess vital signs every visit.
Notify MD of SBP greater than 160 or less than 90; DBP greater than 90 or
less than 60.
Notify MD of Pulse greater than 100 or less than 60.
Notify MD of Respirations greater than 25 or less than 12.
Notify MD of Temperature greater than 100.4 or less than 95.
Glucometer testing to be performed by pcg/pt (frequency) once daily.
Notify MD of BS greater than 250 or less than 70.
REINFORCEMENT OF INTEGUMENTARY MANAGEMENT (with history of
wound)
Assess general condition of skin, awareness of sensation,environmental
moisture, mobility and nutritional status
Reinforce / perform skin care, measures to prevent skin breakdown,
measures to decrease pressure and improve circulation
Assessment includes diabetes ulcers
Reinforce on infection control measures and universal precautions such as
proper hand washing and proper and proper
REINFORCEMENT OF CARDIOVASCULAR MANAGEMENT
Assessment of cardiovascular status every visit to include pulse, changes
in rate and rhythm, pulse deficits, orthostatic hypotension, edema,
dyspnea with exertion, chest pain
Reinforce/monitor compliance on dietary restrictions to include Low Na,
Low fat, Low cholesterol
REINFORCEMENT OF ENDOCRINE/DIABETIC MANAGEMENT
Reinforce/monitor compliance in NCS diet, exercise and activity level /
modification
Reinforce/monitor compliance checking blood sugar every before breakfast
and before dinner and keeping a written record of blood sugar results to
show to MD for treatment reference
SN to check pts BS during visit if pt did not check his BS prior to visit
Reinforce in diabetic neuropathy, importance of foot care including
monitoring for the presence of skin lesions on the lower extremities, proper
footwear and effects of temperature changes
Reinforce in diabetic retinopathy, importance of regular eye examination,
proper eye wear
ESRD/ Dialysis management
SN to continously monitor Pt status during visit and coordinate to the
dialysis unit for any significant findings that may need urgent care or
emergency dialysis.
FALL PREVENTION/SAFETY MEASURES

Reinforce/monitor compliance on safety measures to prevent fall / injury

and medication error.

RECERTIFICATION
SN ORDERS
FREQ 1wk9
Assess VS and all body system, knowledge of Disease Process and its
associated care and treatment, medication regimen knowledge, and s/s
complications necessitating medical attention.
Notify MD of SBP greater than 160 or less than 90; DBP greater than 90 or
less than 60.
Notify MD of Pulse greater than 100 or less than 60.
Notify MD of Respirations greater than 20 or less than 12.
Notify MD of Temperature greater than 100.4 or less than 95.
Glucometer testing to be performed by pcg/pt once daily.
Notify MD of BS greater than 250mg/dl or less than 70mg/dl
CARDIOVASCULAR MANAGEMENT
Assessment of cardiovascular status every visit to include pulse, changes
in rate and rhythm, pulse deficits, orthostatic hypotension, edema,
dyspnea with exertion, chest pain
Instruct the patient proper technique for checking blood pressure and
pulse keeping a record of readings to show MD, and notify MD if results are
greater than identified parameters
Reinforced the Pt./Pcg dietary restrictions to include Low Na, Low fat, Low
cholesterol
Reinforced on measures to recognize cardiac dysfunction and relieve
complication
Reinforced on energy conservation techniques to include rest periods in
activities to limit fatigue
Instruct in use of Nitroglycerin to relieve chest pain
Weigh patient every visit
Notify physician of weight variation of 5 lbs a week
Reinforced on methods to detect / alleviate fluid retention
Reinforced on lifestyle modifications such as regular physical activity and
reduced sodium intake.
Assist Patient to identify modifiable risk factors that increases blood
pressure
Reinforced on the importance of adhering to treatment regimen and
keeping follow up appointments
Reinforced patients in establishing a daily routine for taking medications,
to keep a record of drugs, report for any adverse reactions

Instruct on stress reduction activities and energy reservation, rest,

avoidance of stress tension (physical and mental rest)
Determine patients specific questions related to health maintenance
Discuss non compliance with instructions or programs to determine
rationale for failure
ENDOCRINE/DIABETES MANAGEMENT
Blood glucose testing
Reinforced Pt./Pcg. in s/sx of hypo/hyperglycemia
Reinforced in NCS diet, exercise and activity level / modification
Reinforced Pt./Pcg in use, care and calibration of glucometer
Reinforced patient in rationale of keeping a written record of blood sugar
results to show to MD for treatment reference
Reinforced Pt./Pcg to check blood sugar daily
Reinforced in diabetic neuropathy, importance of foot care including
monitoring for the presence of skin lesions on the lower extremities, proper
footwear and effects of temperature changes
Reinforced in diabetic retinopathy, importance of regular eye examination,
proper eye wear
Reinforced in changes to healing process because of diabetes
ANTICOAGULANT MANAGEMENT
Reinforced patients to notify MD when manifestations of bleeding occurs to
include nosebleed that starts spontaneously or does not stop soon,
bruising that happens suddenly or is large, coffee ground like or blood on
vomit, diarrhea, stool, or dark starry stool, heavy menstrual periods,
bleeding gums, arthritic-type symptoms (damage from bleeding into
joints), loss of vision.
Reinforced regarding warfarin interaction with diet rich in vitamin K such as
swiss chard, kale, brussels sprouts, broccoli, spinach and green tea.
Reinforced pt/pcg to avoid caffeine and alcohol which may interact with
anticoagulant effect.
Instruct pt/pcg to notify MD, dentist and pharmacist that there's ongoing
anticoagulant therapy before procedures.
Reinforced pt/pcg that because of the risk of heavy bleeding, sports and
other potentially hazardous activities should be avoided to avoid injuries.
Reinforced pt/pcg that any falls, blows to the body or head, or other
injuries should be reported to a physician, as internal bleeding may occur
without any obvious symptoms.
Reinforced pt/pcg that special care should be taken in shaving and in
brushing and flossing the teeth.
Reinforced pt/pcg that soft toothbrushes should be used and the flossing
should be very gentle.
Reinforced pt/pcg that electric razors should be used instead of a blade.
SAFETY/FALL MANAGEMENT
Reinforced Pt./Pcg.on safety measures to prevent fall / injury
Implement and instruct medication regimen, including dosage, side effects,
name, route, frequency, desired action and adverse reaction

Reinforced medication compliance / medication set-up

Reinforced safe ambulation / bed / chair transfer
Reinforced Pt./Pcg. on how to access emergency aid
SN GOALS
Stable cardiovascular throughout treatment plan as evidenced by BP within
90/60 mmHg and 160/90 mmHg, PR 60-100 / min, and no s/sx of
Hypertension, hypotension or heart failure exacerbation
The Pt./Pcg will be able to to identify s/sx of cardiac distress to report to
the MD and when to seek care at an acute care facility throughout
treatment plan
The Pt./Pcg will verbalize and demonstrate techniques to minimize edema
within 3 weeks with compliance to medications and dietary restrictions
The patient will be able to verbalize and demonstrate understanding and
compliance with dietary restrictions and identify appropriate food choices
with the use of dietary diary, and demonstrate adherence to order
throughout treatment plan
The Pt./Pcg will be able to verbalize the administration of Nitroglycerin to
relieve chest pain
Patient demonstrate adaptive coping behaviors by identifying risk factors
that elevate blood pressure within certification period
Patient maintain adequate cardiac output and hemodynamic stability
The Pt./Pcg will be able to verbalize and demonstrate adequate hydration
as evidenced by good skin turgor / urine is clear, yellow throughout
treatment plan
Stable GU status throughout treatment plan
The Pt./Pcg will verbalize symptoms of hypo / hyperglycemia
The Pt./Pcg will verbalize and demonstrate compliance with 1.5L/day fluid
restriction, low sodium, low cholesterol and no concentrated sugar diet and
exercise as evidenced by blood sugar results within 70mg/dl to 250mg/dl
throughout treatment plan
Pt demonstrates compliance to medications and NCS diet
The Pt./Pcg will demonstrate competency in the use, care and calibration
of glucometer by independently performing treating and recording blood
sugar results with 100% accuracy within 3 weeks
The Pt./Pcg will verbalize and demonstrate proper disposal of lancets for
blood sugar testing
The Pt./Pcg will verbalize and demonstrate good foot / skin care as
evidenced by no skin breakdown during certification period
The Pt./Pcg will verbalize disease process of diabetes including adverse
s/sx of impending problems to report to the physician throughout
treatment plan
Will increase safe, functional ability by demonstrating ability to ambulate
throughout treatment plan
Will verbalized understanding and demonstrate compliance with safety, fall
precautions throughout treatment planWill have no evidence of fall, injury
and skin breakdown throughout treatment plan

Takes all medication with respect to timing with 1-2 weeks and throughout
treatment plan

SN 1Wk1, 2Wk8
Assess VS and all body system, knowledge of Disease Process and its
associated care and treatment, medication regimen knowledge, and s/s
complications necessitating medical attention.
Notify MD of SBP greater than 160 or less than 90; DBP greater than 90 or
less than 60.
Notify MD of Pulse greater than 100 or less than 60.
Notify MD of Respirations greater than 20 or less than 12.
Notify MD of Temperature greater than 100.4 or less than 95.
RESPIRATORY
Instruct Pcg regarding disease process related to Emphysema
Assess respiratory status, rate and rhythm, breath sounds, lung expansion
Assess for breathing pattern
Assess abnormal breath sounds and s/sx of respiratory distress
Assess sputum production and character, frequency and amount
Perform pulse oximetry
Chest physiotherapy
Instruct on proper positioning with proper body alignment for optimal
respiratory excursion/ facilitate ventilation/perfusion matching
Instruct to monitor local air quality reports for potential allergens /
pollutants that may increase breathing problems

Instruct in action, dosage frequency and safety, side effects of respiratory

medications.
Assess/Monitor physical environment/inhale irritants that may precipitate
exacerbation
Assist patient in establishing/following a medication management system,
usage and signs of adverse reactions
Instruct pcg on Protection from infection through proper hand washing,
avoidance of exposure to groups/persons with known respiratory infections
Instruct on proper care/disinfection of reusable equipment
Monitor for signs and symptoms of infection such as fever, change in color
and consistency of sputum, chest pain and dyspnea not relieved by usual
methods
Coordination/consultation/and collaboration with other health team
members such as primary physician kept informed of condition and
treatment plan adjusted as needed
Instruct Pcg to report any symptoms including:
Increase SOB and wheezing (more than usual)
A cough that becomes worse; sputum ( increased amount, becomes thicker
than usual, changes in color)
A change in the color of your skin to grey or blue or if you become blue
around lips
Fever of 100.5 F oral or 99.5 F under your arm
Increased swelling in ankles
Fluttering, palpations or irregular beats of hurts
DIGESTIVE/GASTROINTESTINAL/NUTRIONAL MANAGEMENT
SN to assess bowel sounds every visit and identify normal functioning
pattern for patient
Instruct Pt./Pcg.on low salt, low fat, low cholesterol diet compliance
Instruct measuring / recording intake / dietary intake and output, to
promote oral intake and measures to recognize dysfunction and relieve
complications
Instruct in methods to Prevent/Resolve constipation with the use of: High
fiber diet, Increase intake of water and Bulk forms agents
Instruct/review/reinforce teaching regarding four food groups or in
accordance with the food pyramid, proper serving sizes, caloric content of
food and methods of preparation and within dietary restrictions
Instruct to notify SN / MD if no bowel movements for a period greater than
3 days associated with abdominal pain.
HYPOTHYROIDSIM MANAGEMENT
Instruct Pt./Pcg regarding disease process related to Hypothyroidism
SN to monitor vital signs, including heart rate and rhythm.
Instruct Pt/Pcg regarding thyroid replacement therapy.
Instruct Pt/Pcg in low-calorie, low-cholesterol, low-saturated-fate diet.
Assess the Pt for constipation; provide roughage and fluids to prevent
constipation.
Provide a warm environment for the Pt.
Monitor for overdose of thyroid medications, characterized by tachycardia,
restlessness,, nervousness, and insomnia.

Instruct the Pt/Pcg to report episodes of chest pain immediately.

CARDIO/HYPERTENSION MANAGEMENT
Instruct Pt./Pcg regarding disease process related to HTN
Assessment of cardiovascular status every visit to include pulse, changes
in rate and rhythm, pulse deficits, orthostatic hypotension, edema,
dyspnea with exertion, chest pain
Instruct the patient proper technique for checking blood pressure and
pulse keeping a record of readings to show MD, and notify MD if results are
greater than identified parameters
Instruct the Pt./Pcg dietary restrictions to include Low Na, Low fat, Low
cholesterol
Instruct on energy conservation techniques to include rest periods in
activities to limit fatigue
Instruct on lifestyle modifications such as regular physical activity and
reduced sodium intake.
Assist Patient to identify modifiable risk factors that increases blood
pressure
Instruct on the importance of adhering to treatment regimen and keeping
follow up appointments
Instruct patients in establishing a daily routine for taking medications, to
keep a record of drugs, report for any adverse reactions
INTEGUMENTARY/SKIN CARE/PRESSURE ULCER PREVENTION
Assess general condition of skin; specifically over bony prominences
Assess patients awareness of the sensation of pressure
Assess patients mobility and nutritional status
Assess environmental moisture, surface that patients spends majority of
time, amount of shear and friction on patients skin
Instruct/perform strict turning schedules (applicable to
Bedridden/restricted to bed)
Instruct to maintain limbs in functional alignment
Instruct / perform skin care, measures to prevent skin breakdown,
measures to decrease pressure and improve circulation
FALL PREVENTION/SAFETY MEASURES
Instruct Pt./Pcg.on safety measures to prevent fall / injury
Implement and instruct medication regimen, including dosage, side effects,
name, route, frequency, desired action and adverse reaction
Assess medication compliance / medication set-up
Safe ambulation / bed / chair transfer
Instruct Pt./Pcg. on how to access emergency aid
PT ORDERS:
Freq: begins in 2 week , 2wk8
- AAROME's to AROME's to PRE's (B) UE/LE x 10 reps x 2 sets towards AP
on supine position (using therabond).
- Pelvic bridging x 5 reps x 5 secs hold
- Bed mobility exercise as to side to side and supine <-> sit as tolerated.
- Sitting balance exercises x 5 mins or as Pt can tolerate

- Sit to stand exercises when Pt can tolerate

- Standing balance exercises if Pt can tolerate
- ADL training as tolerated.
- HEP as to self- ROM , fall preventive measure and energy conservation
techniques.
- re-evaluation within 30 days.
All exercises include frequent rests in between sets and monitoring of PR
and BP every after exercise.
CARDIOVASCULAR/ATRIAL FIBRILATION/HYPERTENSION MANAGEMENT
Continue assessment of cardiovascular status every visit to include pulse,
changes in rate and rhythm, pulse deficits, orthostatic hypotension,
edema, dyspnea with exertion, chest pain
Reinforced instruction with the patient proper technique for checking blood
pressure and pulse keeping a record of readings to show MD, and notify
MD if results are greater than identified parameters
Reinforced instruction with the Pt./Pcg dietary restrictions to include Low
Na, Low fat, Low cholesterol
Reinforced instruction on measures to recognize cardiac dysfunction and
relieve complication
Reinforced instruction on energy conservation techniques to include rest
periods in activities to limit fatigue
Reinforced instruction on lifestyle modifications such as regular physical
activity and reduced sodium intake.
Assist Patient to identify modifiable risk factors that increases blood
pressure
Reinforced instruction on the importance of adhering to treatment regimen
and keeping follow up appointments
Instruct patients in establishing a daily routine for taking medications, to
keep a record of drugs, report for any adverse reactions
Instruct on stress reduction activities and energy reservation, rest,
avoidance of stress tension (physical and mental rest)
Continue to assess elimination pattern to determine risk for constipation
and straining that may trigger blood pressure to increase
Determine patients specific questions related to health maintenance
Discuss non compliance with instructions or programs to determine
rationale for failure
Reinforced instruction with Pt./Pcg.on safety measures to prevent fall /
injury
EDEMA MANAGEMENT
Inspect skin daily, observe for signs of breakdown
Provide daily skin care: wash with mild soap, rinse, and pat dry; ensure
that skin is thoroughly dried; lubricate skin with lanolin lotion
Report breakdown to nurse immediately
Avoid adhesive tapes directly on skin
Avoid use of tight constricting socks or hose; reposition extremities
frequently. Do not cross legs.
Use cotton or woolen socks that are proper length and size
Wear properly fitting shoes when out of bed; avoid getting barefoot.

RESPIRATORY/OXYGEN MANAGEMENT
Continue to assess respiratory status, rate and rhythm, breath sounds,
lung expansion
Continue to assess for breathing pattern
Continue to assess abnormal breath sounds and s/sx of respiratory distress
Continue to assess sputum production and character, frequency and
amount
Perform pulse oximetry
Reinforced instruction with patient regarding, optimal functioning, and huff
techniques, use of pillow or hand splints when coughing and use of
abdominal muscles for more forceful cough
Important of ambulation and frequent position changes
Provide O2 administration at 2 L min; via NC
Reinforced instruction in use, safety, maintenance, precautions storage
and care of O2 therapy
Reinforced instruction in emergency plan for continued use of O2 in the
event of power shortage
Reinforced instruction in energy conservation, use of accessory muscle,
pursed lip breathing, coughing and deep breathing exercises
Reinforced instruction on proper positioning with proper body alignment for
optimal respiratory excursion/ facilitate ventilation/perfusion matching
Reinforced instruction to monitor local air quality reports for potential
allergens / pollutants that may increase breathing problems
Assess/Monitor for Nutritional status (COPD patients frequently
malnourished because of difficulty eating and increased metabolic rate
from increased effort to breathe) this includes the ff:
Small frequent, easily swallowed meals
Avoidance of high carbohydrate diet that can increase carbon dioxide
levels
Adequate hydration to mobilize secretions
Instruct Pt/Pcg to report any symptoms including:
Increase SOB and wheezing (more than usual)
A cough that becomes worse; sputum ( increased amount, becomes thicker
than usual, changes in color)
Less energy or if it becomes harder for you to do your daily activities
Loss of appetite more than 2 days
A sudden, sharp pain around your lungs, including chest and upper back,
that becomes worse when you breath or cough
If become forgetful or confused
A change in the color of your skin to grey or blue or if you become blue
around lips
If become restless and agitated
Fever of 100.5 F oral or 99.5 F under your arm
Increased swelling in ankles
Fluttering, palpations or irregular beats of hurts
PAIN MANAGEMENT

Continue to assess pain status/characteristics with an accurate use of pain

to include: quality, severity level, location, onset, duration,
precipitating/aggravating, causative and relieving factors
Observe/monitor/Assess s/sx associated with pain includes significant
changes in v/s, color and moisture of skin, restlessness and ability to focus
Continue to assess patients knowledge of or preference for the array of
pain- relief strategies available
Evaluate patients expectation for relief of pain and medications or
therapeutics aimed at abolishing or relieving pain.
Continue to assess pt/pcg willingness or ability to explore a range of
techniques aimed at controlling pain
Monitor/assess for changes in general condition that may herald need for
change in pain relief method
Pt/pcg eliminate additional stressors or sources of discomfort whenever
possible
Reinforced instruction with rest periods to facilitate comfort sleep and
relaxation and intervention to mitigate pain
Monitor/evaluate effectiveness of pain medication, dosage and frequency
and observe for s/sx of untoward effects
Notify MD if intervention are unsuccessful or if current complaint is a
significant change from patients post experience of pain
INTEGUMENTARY MANAGEMENT
Continue to assess general condition of skin; specifically over bony
prominences
Continue to assess patients awareness of the sensation of pressure
Continue to assess patients mobility and nutritional status
Instruct / perform skin care, measures to prevent skin breakdown,
measures to decrease pressure and improve circulation
Reinforced instruction with the Pt./Pcg regarding s/s of infection to include
redness and inflammation, foul odor, purulent discharge and fever, position
to relieve pressure, and proper nutrition to promote healing
FALL/SAFETY MANAGEMENT
Reinforced instruction with Pcg.on safety measures to prevent fall / injury
Reinforced instruction with medication regimen, including dosage, side
effects, name, route, frequency, desired action and adverse reaction
Assess medication compliance / medication set-up
Safe bed / chair transfer
Instruct Pcg. on how to access emergency