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 performed and instructed Jackson Pratt Drain Care: Wash hands with soap and water, remove the plug from the bulb, pour the fluid into a measuring cup (25 ml), clean the plug with an alcohol swab or a cotton ball dipped in rubbing alcohol, squeeze the bulb flat and put the plug back in, the bulb should stay flat until it starts to fill with fluid again, measure the amount of fluid you pour out, write down how much fluid you empty from the JP drain and the date and time you collected it (25 ml, 08/02/21, T15:29), flush the fluid down the toilet, and wash your hands. SN performed and instructed Jackson Pratt Drain Care site: Wash your hands, remove the old bandage, wash your hands again. Wet a cotton swab and clean the skin around the incision and tube site with normal saline solution (salt and water) or, you can use warm, soapy water. Put a new bandage on the incision and tube site. Make the bandage large enough to cover the whole incision area, tape the bandage in place. Patient is incapable of perform JP Drain Care due: complexity of procedure. Patient is unable to learn the technique to perform JP Drain Care due functional, physical, and mental limitations. There is no caregiver willing and able to perform this skilled care. SN instructed patient about Jackson Pratt Care. Seek immediate help if: Your JP drain breaks or comes out. You have cloudy yellow or brown drainage from your JP drain site, or the drainage smells bad. Patient/caregiver verbalized understanding teaching.