SN Frequency:

PT to evaluate and establish treatment plan.

OT to evaluate and establish treatment plan.

ST to evaluate and establish treatment plan.

MSW frequency: 1mo2 to assist with community resources and possible increase in IHSS hours.

CHHA Frequency:
CHHA to assist with ADL's and personal care.

SN to perform skilled observation and assessment of VS and all body systems, medication compliance/effectiveness/reaction to medication, nutrition/hydration, dietary compliance, ADL & mobility status, pain level/control/effectiveness, peripheral circulation, skin integrity, PCG's ability to care for patient and home safety.

SN to check oxygen saturation using pulse oximetry as needed for shortness of breath.

SN to instruct patient/caregiver regarding disease process/management & complications, medication regimen (purpose, effects/side effects, dosage, frequency and administration), pain control and management, energy conservation measures, universal precautions, fall precautions, ADL and ROM exercises, and home safety precautions.

SN to monitor blood sugar if not done by patient/caregiver.
Insulin prepared/administered by _.

SN to notify MD if
BS level less than 60 mg/dl or FBS greater than 350 mg/dl or RBS greater than 400 mg/dl with s/sx of hypo/hyperglycemia;
SBP less than 90 mmHg or greater than 170 mmHg or DBP less than 60 mmHg or greater than 90 mmHg with s/sx of hypo/hypertension; PR less than 60 beats/min or greater than 100 beats/min; RR less than 12/min or greater than 26/min; Temp greater than 100.5°F; pain level greater than 6/10 scale unrelieved by pain meds/pain relief measures, if oxygen saturation level is below 90%; injury/fall incident or any change in medical condition.

SN to weigh patient every visit. Notify MD of weight gain of 3lbs or more every week.

Labs to be done per MD's order.

NS flush 1-2ml prior to start of new bag (N)
Heparin F100units/ML 1-2ml to check for patency PRN (N)

SN to start Heplock and administer _ IVPB daily x _ days. SN to flush heplock with NSS 1-3 mL pre and post antibiotic administration followed by Heparin 1-2 mL (100 units/mL) post infusion. Change Heplock every 3 days and PRN for malfunction.

SN to start Heplock. Change every 3 days and PRN for malfunction. SN to administer _ IVPB via _ Pump every _ hours x _. Flush Heplock with 1-3ml NS prior to start of new bag. May flush with Heparin 100units/ml 1-2ml PRN for sluggish heplock.

SN to change foley catheter with #_fr with 10 ml balloon once a month and PRN for leaking or dislodgement. Irrigate F/C with 50-60 ml NS prn for increase in sediments or for any malfunction. Next foley cath change is due week of _.

SN to administer _. SN to flush PICC line with NS 5-10ml before and after IV infusion. Followed by Heparin 100units/ml 5-10ml after final NS flush. PICC line care dressing change every week. Cleanse site with betadine x 3, alcohol x 3. Cover with DSD

. Pt/PCG will verbalize understanding of disease process, management and complications in 2-3 weeks.
. Demonstrate understanding and compliance with medication regime in 2-3 weeks.
. Blood sugar will be controlled between 80-120mg/dl throughout treatment period.
. BP will be controlled between 90/70-120/80 throughout treatment period.
. Breathing will be easy and non labored throughout treatment period.
. Pain will be controlled between 0-1 at the pain scale throughout treatment period.
. Patient will be safe at home free from injury throughout treatment period.
. _ will heal without complications in 3-4 weeks.
. Wound will heal without complication upon completion of antibiotic therapy.
. Infection will resolve upon completion of antibiotic therapy.
. Infection will resolve upon completion of antibiotic, as evidence by absence of fever and malaise.
. Heplock will remain patent and free of infection throughout treatment period.
. Heplock will remain patent and free from infection throughout treatment period.
. No episode of UTI throughout treatment period.
. No evidence of bleeding throughout treatment period.
. Foley Catheter will remain patent throughout treatment period.
. Keep Hemoglobin at 11 g/dl throughout treatment period.
. PT/INR will be maintained at a therapeutic level. INR between 2-3 throughout the treatment period.
. Stable musculoskeletal status as evidenced by improved muscle strength and mobility, stable gait in 5-6 weeks.
. Stable musculoskeletal status as evidenced by improved muscle strength and mobility, stable gait, and absence of fall/injury and be safe at home within 6-9 weeks.
. Patient will be adequately hydrated as evidenced by good skin turgor and normal electrolyte after completion of IV therapy.
. Anemia will resolved as evidenced by Hgb level between 11-12gm/dl.
. Pt/CG will be able to prep/admin Epogen in 3-4 weeks.
. Patient's Gastrostomy site will remain patent and free of infection throughout certification period
. PCG will be verbalized understanding and competence on correct techniques of  GT feeding / flushing/ medication administration in order to prevent aspiration; identifies causative/risks factors. Patient will experience no aspiration as evidenced of clear breath sounds, noiseless respirations throughout the certification period.
. Patient will be able to ambulate without difficulty using FWW in 3-4 weeks.

REHABILITATION POTENTIAL: Fair for patient to achieve stated goals by the end of the certification period.


DISCHARGE PLANS: Discharge patient when goals are met. Patient to remain in current home situation with assist from family and caregiver under MD supervision.


Discharge Summary available upon request