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. Feeding tube placement verified by auscultation. SN administered via PEG tube feeding with Isosource 1.5 Cal formula at 325 mL/hr for 6 hours per day. Total feed to be received: 1000 ml (1500-0700). Flush feeding tube with 60 mL water every 12 hours. Feeding tube was water flush with 100 ml of water before and after feed. HOB kept elevated. Feeding tube site is clean and dry without drainage, patent & intact. Amount residual checked: 30 ml. SN instructed and performed feeding tube site care as follows: cleanse with NS, pat dry, apply DSD and secure with tape daily. Instructed in preparation/storage of feeding and use of equipment. Patient is incapable of perform enteral feeding due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN instructed patient/caregiver call nurse or doctor if your body changes: Nausea or vomiting that does not go away, constipation with no bowel movement for 3 days. Diarrhea of more than 6 loose stools a day, stomach becomes bloated or swollen and tight, a stomach residual more than the amount your doctor has set for you. Patient/caregiver verbalized understanding teaching.