ORDERS FOR DISCIPLINE AND TREATMENTS

SN FREQUENCY : ___________
SN ORDERS : SKILLED OBSERVATION/ASSESSMENT, ASSESS VITAL SIGNS
AND SIGN/SYMPTOMS OF COMPLICATIONS: _________ SYSTEM.
ASSESS PATIENT’S RESPONSE TO AND COMPLIANCE WITH PLAN OF CARE
ON EVERY VISIT.
INSTRUCT /EVALUATE UNDERSTANDING OF : DISEASE PROCESS,
MEDICATION REGIMEN, ( ACTION/SIDE EFFECTS), DETECTING
COMPLICATIONS, DIET/NUTRITIONAL STATUS, SAFETY PRECAUTIONS AND
EMERGENCY MEASURES.

( INSERT ORDERS HERE)

REPORT ANY SIGNIFICANT CHANGES IN PATIENT’S CONDITION TO

PHYSICIAN. TEACHING AND TRAINING: DISEASE PROCESS, MEDICATION
REGIMEN, SKIN CARE/DIET/NUTRITION/HYDRATION, SYMPTOM CONTROL
MEASURES, SAFETY, PREVENTION OF INJURIES AND EMERGENCY PLANS.

TYPE OF SKILL SERVICE REQUIRED: ASSESSMENT/OBSERVATION:

(list systems to be reported, s/s and complications to report)
MANAGEMENT AND EVALUATION.

PAIN STATEMENTS : SN TO ASSESS PAIN LEVEL

(TYPE/FREQUENCY/INTENSITY/IIRADIATION) INSTRUCT ON PAIN CONTROL
MEASURES , ASSESS FOR PATIENT RELIEF.

FALL STATEMENTS : SN TO ASSSESS PATIENT FOR FALL RISK AND

REASSESS AS NECESSARY WITHIN 30 DAYS. SN TO INSTRUCT PATIENT
/CAREGIVER ON SAFETY MEASURES, SAFE USE OF ASSISTIVE DEVICE
( WALKER, CANE), AND SAFE AMBULATION.

WOUND CARE:
SN TO ASSESS INTEGUMENTARY STATUS.
SN TO PERFORM WOUND CARE (FREQ) TO WOUND/ULCER IN (LOCATION)
WHICH MEASURES AS FOLLOWS:
L: CM X W: CM X D: CM, WITH __ AMOUNT OF __
DRAINAGE, __ ODOR, __ EDEMA, __ UNDERMINING/TUNNELING,
PERIWOUND IS INTACT AND WOUND BED IS PINK WITH GRANULATION
TISSUE.
SN TO PROVIDE THE FOLLOWING WOUND CARE: " "
FOLLOWING ASEPTIC TECHNIQUES AND UNIVERSAL PRECAUTIONS.
SN TO ASSESS WOUND FOR SIGN/SYMPTOMS OF
HEALING/INFECTION/COMPLICATIONS, AND REPORT WOUND
STATUS/PROGRESS TO PHYSICIAN __________________
SN TO MEASURE WOUND EVERY WEEK, ASSESS DRAINAGE ON EACH VISIT
FOR AMOUNT, COLOR, ODOR, AND CONSISTENCY.
INSTRUCT PATIENT IN WOUND CARE PROCEDURE, WAYS TO PROMOTE
WOUND HEALING, SIGNS /SYMPTOMS OF HEALING/COMPLICATIONS TO
REPORT TO PHYSICIAN.
PATIENT IS UNABLE TO PERFORM OWN WOUND CARE DUE TO:
_______________________________________________________________________
___________________________________________________________________
NO CARE GIVER AVAILABLE TO ASSIST THE PATIENT WITH WOUND CARE.

INJCETABLE MEDICATION:
SN TO ADMINISTER ( MEDICATION, DOSE, ROUTE , FREQUENCY, DURATION)
FOLLOWING ASEPTIC TECHNIQUES, UNIVERSAL PRECAUTIONS, SITE
ROTATION METHOD, AND PROPER DISPOSAL OF SHARPS. PATIENT IS
UNABLE TO ADMINISTER OWN ____ ( ROUTE)
INJECTION AS ORDERED BY PHYSICIAN, DUE TO : ( REASON) ________.

IV THERAPY :
SN ADMINSITERED ______ ( MEDICATION, DOSAGE IN ML, FREQUENCY, RUN
OVER ________ ( HOUR/MIN.) VIA __________ ( CATHETER TYPE AND
LOCATION) VIA ( GRAVITY OR IV PUMP ( TYPE).
( ADD FLSUH PROTOCOL)
SN TO FLUSH FIRST WITH _____ ML OF NSS /HEPARIN, THEN ADMINISTER
( MEDICATION) AND THEN FLUSH AFTER ADMINISTRATION OF MEDICATION
WITH __ ML OF __________ . SN CHANGE IV SITE DRESSING EVERY
________ HOURS.

( ADD LABORATORY IF APPLICABLE)

PEG TUBE CARE

SN TO PERFORM PEG SITE CARE AND PEG FEEDINGS OF ____ VIA ___
FLUSHING WITH _____CC OF WATER AFTER EACH FEEDING, AND WITH
______CC OF WATER AFTER MEDICATION ADMINISTRATION.
SN TO TEACH AND ASSESS PATIENT / CAREGIVER ABILITY TO
PERFORM PEG FEEDING AND PEG SITE CARE INCLUDING PREPARATION
AND STORAGE OF FEEDING, EQUIPMENT CARE, FLUSHING TECHNIQUE,
FLOW RATE CALCULATION, ASSESSMENT OF PEG SITE FOR SIGNS OF
INFECTION, PRN VISITS FOR CLOG, LEAK OF MALFUNCTION.
FOLEY CATHETER

SN TO PERFORM FOLEY MAINTENANCE (FREQ) UTIIZING ____FR/FOLEY

WITH ____CC/BALLO ___ PRN VISITS FOR CLOG, LEAK, OR
ACCIDENTAL REMOVAL. LAST FOLEY CHANGE PERFORMED ON (DATE).
SN TO IRRIGATE FOLEY WITH ___CC OF ____ (FREQ) AND PRN FOR
_____. SN TO TEACH AND ASSESS PATIENT / CAREGIVER ABILITY TO
CARE FOR INDWELLING CATHETER. *FOR INFUSIONS/IVS* SN TO
ADMINISTER (MED) VIA (CATH) (FREQ), AS PER PHYSICIAN'S
ORDERS, SEE BOX 10. SN TO FLUSH (CATH) W/(NSS) PRIOR TO ADMI

BLOOD PRESSURE

SKILLED OBSERVATION/EVALUATION, ASSESS VITAL SIGNS AND

SYMPTOMS OF COMPLICATIONS, WITH SPECIAL ATTENTION TO
CARDIOVASCULAR SYSTEM. SN TO ASSESS CARDIOVASCULAR STATUS,
MONITOR BLOOD PRESSURE ON EACH NURSING VISIT, AND MANTAIN
RECORD OF THE SAME, CALL PHYSICIAN IF BLOOD PRESSURE GREATER
THAN 140/90 MMHG OR LOWER THAN 100/60 MMHG. SN TO ASSESS FOR
SIGNS/SYMPTOMS OF UNCONTROLLED HYPERTENSION: TINNITUS,
DIZZINESS, OR NASAL BLEEDING. SN TO ASSESS FOR IRREGULAR HR,
PALPITATIONS, TACHYCARDIA OR BRADYCARDIA, FLUID RETENTION OR
EDEMA. SN TO INSTRUCT PATIENT ON DISEASE PROCESS/COMPLICATIONS,
PROGRESS OF DISEASE, DIET AND COMPLIANCE WITH NUTRITIONAL
REQUIREMENT, NEW MEDICATIONS, SIDE/ADVERSE EFFECTS TO REPORT
TO PHYSICIAN, WHEN TO DISCONTINUE MEDICATION, AND ADEQUATE
USE, SAFETY/EMERGENCY MANGEMENT, AND FOLLOW UP WITH
PHYSICIAN. SN TO REPORT ANY SIGNIFICANT FINDINGS TO
NURSE/AGENCY.

PT FREQUENCY :

RPT TO PERFORM INITIAL EVALUATION WITH FOLLOW UP VISITS

FOR PHYSICAL THERAPY SERVICES.
RPT TO ASSESS/EVALUATE MUSCLE STRENGH, ROM, AMBULATION,
BED MOBILITY, TRANSFER ABILITY, COORDINATION, BALANCE,
ENDURANCE, DISEASE PROCESS, PAIN, HOME SAFETY AND ADL'S.
RPT TO PROVIDE PATIENT WITH HOME EXERCISE PROGRAM. :
RPT TO SUPERVISE PTA/AIDE VISITS EVERY 14 DAYS.
( PUT SPECIFIC ORDERS/GOALS)

AIDE FREQUENCY:
( SPEFIC ORDERS AND FREQUENCY : DAILY OR PRN)
GOALS

SN GOALS:

1) PATIENT WILL VERBALIZE UNDERSTANDING OF DISEASE PROCESS

AND CURRENT HEALTH STATUS.
2) PATIENT WILL VERBALIZE UNDERSTANDING OF THERAPEUTIC DIET
3) PATIENT WILL VERBALIZE UNDERSTANDING OF S/S TO REPORT TO
PHYSICIAN.
4) PATIENT WILL RETURN TO OPTIMUM ENDOCRINE STATUS W/O
COMPLICATIONS OR FURTHER PROGRESSION OF DISEASE PROCESS.
( BE SPECIFIC WITH OASIS GOALS)

PT GOALS:

RPT GOALS:
1) PATIENT WILL DEMONSTRATE ABILITY TO FOLLOW HEP.
2) PATIENT WILL ATTAIN MAXIMUM JOINT MOBILITY AND MUSCLE
STRENGH.
3) PATIENT WILL BE INDEPENDENT OR BE ABLE TO PARTICIPATE
IN ACTIVITIES OF DAILY LIVING.
4) PATIENT WILL BE COMFORTABLE WITH IN HOME SETTINGS.
5) OPTIMUM FUNCTION WILL BE ATTAINED AND MAINTAINED.

AIDE GOALS:

AIDE GOAL: AIDE WILL PROVIDE PERSONAL CARE IN ORDER TO

MAINTAIN AN OPTIMAL LEVEL OF PATIENT'S PERSONAL HYGIENE. THE
PATIENT WILL REMAIN SAFE, CLEAN AND COMFORTABLE WITH
EFFECTIVE CARE; PERSONAL CARE NEEDS WILL BE MET.

WOUND CARE GOALS

SN GOAL: ONGOING PATIENT AND CAREGIVER WILL DEMONSTRATE

COMPLIANCE WITH DIABETIC CARE AND INSTRUCTIONS; WILL
IDENTIFY S/S OF HYPO/HYPERGLYCEMIA AND MEASURES TO PREVENT
DIABETIC COMPLICATIONS. PATIENT WILL LEARN GOOD SKIN CARE
AND PREVENT ANY SKIN BREAKDOWN. PATIENT WILL DEMONSTRATE
INCREASED HEALING PROCESS WITHOUT ANY S/S OF INFECTION OR
OTHER COMPLICATIONS.