VIEW COMPLETED NOTE

Patient identified by name, ID with picture and facial recognition. SN performed skilled observation and assessment of all body systems from head to toe. No signs or symptoms of acute distress noted. SN assessed home for safety & Risks for fall. Safety & preventative education. SN performed skilled observation and assessment, monitored vital sign and blood pressure and found them within normal limits. SN assessed mental and physical status, evaluated compliance, effectiveness and side effects of medication, diet and nutritional status, and patient’s and/or caregiver’s knowledge of signs and symptoms of complication. SN assessed Port-A-Cath single lumen port site on right chest. No signs and symptoms of infection. After locating the port area (palpate the dome) SN cleansed using chlorhexidine solution 0.5% and apply it using a back-and-forth motion for at least 30 seconds allow to dry. The access needle was primed and capped extension tubing with normal saline solution. Extension tubing was clamped. Once stabilized the dome between thumb and two fingers of one hand in a tripod fashion, at a 90 degree angle to the dome, the access needle was pushed firmly through the sin and septum into the centre of the Port-A-Cath until the needle lightly touched the base of the port. With a 10mL syringe was Withdrawn 2.5 mL of blood and the patency was confirmed. Extension tubing was clamped and discard the blood. 10 mL of sodium chloride 0.9% was injected. The extension clamp was closed and entire site was covered with a transparent dressing. SN infused Meropenen 1 gm in 100 ml of NSS over 30 minutes via port-a-cath and gravity with a control rate of infusion at 200 ml/hr once daily for 3 days. After infusion, SN instilled 10 ml of sterile NS followed by 5 ml of heparin (100unit/ML). While anchoring the port, SN removed the non-coring needle fully intact and discarded it into the sharps container. No residual or blood noted once the needle was removed from the port. A sterile bandage was applied. Patient tolerated procedure well without complaint or complications. Standard and universal precautions were used. Patient is incapable of perform Port-A-Cath IV Infusion due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN instructed patient/caregiver on signs of central catheter problems. The signs of catheter infection and problems are similar for all types of central venous catheters. If you have any sign of infection or catheter problem, call your doctor immediately. In addition, signs of infection, clotting, or other problems include: Redness, tenderness, drainage, warmth, or odor around the catheter site Fever of 100.5F (38 C) or greater, or chills, swelling of the face, neck, chest, or arm on the side where your catheter is inserted, leakage of blood or fluid at the catheter site or the cap, inability to flush the catheter, or resistance to flushing the catheter, displacement or lengthening of the catheter. Patient/caregiver verbalized understanding teaching.