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. The irrigation set was opened and the irrigation syringe was filled with 50 ml of saline solution ( Catheter Type: Foley) and place it in the sterile tray. Catheter tube was release from drainage tube and the connection between the drainage tube and the catheter was cleansed carefully using an alcohol wipe. It was inserted the irrigation syringe into catheter tube. Slowly and gently was injected the irrigation solution as per doctor’s instructions. Solution flowed freely and without resistance. Syringe was removed from the catheter tubing and allow the irrigation solution to flow back out of the bladder and into the drainage tray. The end of the drainage tube was cleaned with an alcohol wipe. It was reconnect the catheter tube to the drainage bag tubing and the fluid started to drain into the bag. Patient tolerated procedure well without complaint or complication. Standard and universal precautions were used. Patient is incapable perform of urinary catheter irrigation due: complexity of procedure, poor manual dexterity. There is no caregiver willing and able to perform this skilled care. SN instructed that urinary tract infection generally develops when bacteria enter the urinary tract and begin multiplying. The most common urinary tract infections are cystitis, which affects the bladder, and urethritis, which affects the urethra. Urinary tract infections are the second most common type of infection that develop in the body. Symptoms of the infection include burning or pain during urination, an urge to urinate often, pressure in the lower belly, foul-smelling urine, back pain below the ribs, tiredness or shakiness, fever and urine that looks reddish or cloudy. A urinary tract infection is more likely to occur in women than men, and it affects people of all ages. Patient/caregiver verbalized understanding teaching.