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. SN accessed PICC Line to left arm, there is no s/s of infection IV site is healthy. SN checked blood return. SN flushed IV line with 10 ml sterile normal saline 0.9%, line was patent and flowed freely with no resistance. SN infused Meropenen 1 mg in 250 ml of NSS over 60 minutes via PICC Line and mechanical pump with a control rate of infusion at 122 ml/hr once daily for 7 days. After infusion, SN flushed line with 10ML of sterile saline. Patient tolerated procedure well without complaint or complications. Standard and universal precautions were used. Patient is unable to perform self-infusion due: complexity of procedure. Patient is unable to learn the technique to safely infused this medication due: functional, physical, and mental limitations. There is no caregiver willing and able to perform this skilled care. SN instructed patient/caregiver on signs of central catheter problems. The signs of catheter infection and problems are similar for all types of central venous catheters. If you have any sign of infection or catheter problem, call your doctor immediately. In addition, signs of infection, clotting, or other problems include: Redness, tenderness, drainage, warmth, or odor around the catheter site Fever of 100.5F (38 C) or greater, or chills, swelling of the face, neck, chest, or arm on the side where your catheter is inserted, leakage of blood or fluid at the catheter site or the cap, inability to flush the catheter, or resistance to flushing the catheter, displacement or lengthening of the catheter. Patient/caregiver verbalized understanding teaching.