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 assessed PEG tube placement/site, patency, surrounding skin, and patient’s tolerance to enteral feeding. PEG tube was patent and intact. Insertion site was clean and dry with no drainage, redness, swelling, irritation, or other signs/symptoms of infection noted. Gastric residual was checked prior to feeding and measured 30 mL. SN administered Jevity 1.5 Cal formula 125 mL every 6 hours via PEG tube as ordered. Prescribed total daily feeding volume is 1100 mL. PEG tube was flushed with 50 mL of water before and after feeding to maintain tube patency and provide hydration as ordered. Head of bed was maintained in an elevated position during feeding and afterward to reduce the risk of aspiration. Patient tolerated feeding well with no nausea, vomiting, abdominal discomfort/distention, coughing, choking, respiratory distress, or other immediate complications noted. SN performed PEG tube site care as ordered. Site was cleansed with normal saline, patted dry, covered with a dry sterile dressing (DSD), and secured with tape. Standard precautions and appropriate infection-control technique were maintained throughout the procedure. Instructed in preparation/storage of feeding and use of equipment. Patient is incapable of perform enteral feeding due: complexity of procedure, poor manual dexterity. There is no caregiver willing and able to perform this skilled care. SN instructed Patient/Caregiver regarding proper PEG tube care, maintaining tube patency, prescribed feeding and water-flush schedule, proper positioning during feeding, and signs/symptoms of complications to report, including redness, swelling, drainage, leakage, pain, tube blockage or displacement, nausea/vomiting, abdominal distention, feeding intolerance, coughing, choking, or respiratory difficulty. Patient/Caregiver verbalized understanding of teaching provided. Patient/caregiver verbalized understanding teaching.