Patient was identified by 2 ID documents. SN performed skilled observation and assessment, monitored vital signs, assessed mental, physical and behavioral status. Instructed, evaluated and assessed PT/CG compliance, effectiveness and side effects to medications, instructed on diet plan, assessed patient and caregivers understanding of disease process, Pt/CG education provided. Assessed & educated PT/CG knowledge of signs and symptoms re: Complications necessitating medical attention. Instructed PT/CG in any knowledge deficit. Assessed home for safety & Risks for Falls. Safety & preventative education provided. Implemented Safety measures as needed. SN draw blood for blood test. Procedure was done following aseptic techniques and universal precautions. SN educated Pt/CG on safety measures regarding need for adequate lighting in passageways, especially at night; also, keep passageways free of clutter, tangled cords; wipe up spills immediately to prevent falls.
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