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 removed old dressing. No signs and symptoms of of infection, wet, dirty, loose, or has started to lift from skin to catheter exit site. Catheter no damaged, cut, kinks, bends or broken. SN drain the pleural fluid using Pleurx Drainage Kit and Procedure Pack as directed and per sterile technique. SN attached PleurX catheter to a vacuum bottle, after open roller clamp the pleural fluid started flow into the drainage line and vacuum bottle. Pleural fluid amount: 250 ml, Pleural fluid type: Transudate, red color. New dressing: with an alcohol pad SN clean the skin around the catheter, air dry for 30 seconds, place the new foam pad under the catheter. The catheter was winded into loops and place it over the sponge drain and cover the catheter with gauze pads and a transparent dressing very visit. Equipment was remove and disposed appropriately. Patient tolerated procedure well without complaint or complications. Standard and universal precautions were used. Patient is incapable of perform Pleural drainage due: complexity of procedure. There is no caregiver willing and able to perform this skilled care. SN instructed patient/caregiver about the potential complications of draining the pleural space include, but may not be limited to, pneumothorax, re-expansion pulmonary edema, hypotension, circulatory collapse and infection. Do not drain more than 1,000 mL of fluid from your chest at any one time. Patient/caregiver verbalized understanding teaching.