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 has a colostomy with pouch intact in place to left lower quadrant (LLQ). Stoma Appearance: pinkish-red, Stool Appearance: formed, Surrounding Skin: intact. SN performed ostomy care as follows: old pouch and wafer were removed, clean area around the stoma with NSS 0.9%, pat dry, apply skin barrier protector around the stoma, is left to dry, and new wafer with the right size opening was applied, then attach the pouch onto the wafer, following universal precautions and aseptic technique. Patient is incapable of perform ostomy care due: complexity of procedure. Patient is unable to learn the technique to perform ostomy care due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN instructed patient/caregive on Colostomy Care. You contact your healthcare provider if: You have a fever, you have a foul odor coming from your colostomy bag or stomach that lasts longer than a week, your skin around the stomach becomes red and irritated, you have nausea, vomiting, pain, cramping, or bloating, you do not have regular bowel movements through your stomach, the size of your stomach changes, you have questions or concerns about your condition. Patient/caregiver verbalized understanding teaching.