VIEW COMPLETED NOTE

Patient identified with Name, DOB, ID and Address prior to perform all procedures. SN performed skilled observation and assessment, monitored vital signs, assessed mental, physical and behavioral status. Instructed, evaluated and assessed pt compliance, effectiveness and side effects to medications. Instructed on diet plan. Assessed patient understanding of disease process. Patient education provided. Assessed & educated patient knowledge of signs and symptoms re: complications necessitating medical attention. Instructed patient in any knowledge deficit. Assessed home for safety & Risks for Falls. Safety & preventative education provided. Implemented safety measures as needed.. SN clean the 3 way stopcock with position off to the drainage bag. The flushing port was cleaned with alcohol swab. SN flushed port with 10 ml normal saline. Then attached the flush syringe and inject gently the solution. Turned the stopcock off position to flushing port and open to the drainage bag. The collection bag was emptied. Urine appearance: yellow and clear; amount: 250 ml. SN removed old dressing. No signs and symptoms of of infection, wet, dirty, loose, or has started to lift from skin to catheter exit site. Catheter no damaged, cut, kinks, bends or broken. SN clean skin around Nephrostomy catheter with Normal Saline, pat dry, a split gauze 2×2 secure with transparent film dressing was apply every daily. Equipment was remove and disposed appropriately. Patient tolerated procedure well without complaint or complications. Standard and universal precautions were used. Patient is unable to perform self-flushed nephrostomy due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN instructed patient/caregiver were explained that having a nephrostomy tube in for a long time increases the risk of getting an infection. Nephrostomy tube care focuses on preventing infection. Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse call line if you are having problems. It’s also a good idea to know your test results and keep a list of the medicines to take. Patient/caregiver verbalized understanding teaching.