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. Patient in comfortable position. SN locate the appropriate site for venipuncture on right cubital fossa, per sterile technique, SN cleanse area the site with chlorhexidine using friction for 30 seconds and allow to air dry for 30 seconds. A tourniquet was applied. Selected vein was stabilized using the non-dominant hand, a 22 Gauge catheter was inserted in the first attempt and positive blood return in catheter. Applying security measures the extension tubing attached. Tourniquet was release. Sterile transparent dressing over site was applied and tubing secure using securement device. IV tubing connected and adjusted rate as per physician’s order. Equipment was remove and disposed appropriately. Labeled site with date and time, gauge of cannula and initials. Patient tolerated procedure well without complaint or complications. Standard and universal precautions were used. Patient is unable to perform peripherical IV due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN instructed patient/caregiver about Phlebitis. This is inflammation of the vein. It is a common complication associated with intravenous therapy. It may occur up to 48 hours after catheter removal. Patient/caregiver verbalized understanding teaching.