VIEW COMPLETED NOTE

SN to instruct Patient/Caregiver on turning/repositioning every 2 hours, SN to instruct the Patient/Caregiver to float heels, SN to instruct the Patient/Caregiver on methods to reduce friction and shear, SN to instruct the Patient/Caregiver to pad all bony prominences, SN to assess skin for breakdown every visit, SN to assess/evaluate wound(s) at each dressing change and PRN for signs/symptoms of infection. Report to physician increased temp >100.5, chills, increase in drainage, foul odor, redness, unrelieved pain > on 0-10 scale, and any other significant changes., SN to instruct the Patient/Caregiver on signs/symptoms of wound infection to report to physician, to include increased temp >100.5, chills, increase in drainage, foul odor, redness, unrelieved pain > on 0-10 scale, and any other significant changes., SN to assess the client’s nutritional status., SN to assess for urinary and fecal incontinence., SN provide local wound care as prescribed.