101568 FUENTES, ALVINO 07/25/2023-09/22/2023

Oasis REC- Done/status validated

POC-Done

MD order-Done

Diagnoses

I87.2 Venous insufficiency (chronic) (peripheral)

L97.922 Non-prs chr ulc unsp prt of l low leg w fat layer exposed

I12.9 Hypertensive chronic kidney disease w stg 1-4/unsp chr kdny

N18.9 Chronic kidney disease, unspecified

I25.10 Athscl heart disease of native coronary artery w/o ang pctrs

N40.0 Benign prostatic hyperplasia without lower urinry tract symp

M19.019 Primary osteoarthritis, unspecified shoulder

M10.9 Gout, unspecified

E66.01 Morbid (severe) obesity due to excess calories

Z79.82 Long term (current) use of aspirin

Z68.41 Body mass index [BMI] 40.0-44.9, adult

Venous insufficiency (chronic) (peripheral), Non-prs chr ulc unsp prt of l low leg w fat layer exposed,
Hypertensive chronic kidney disease w stg 1-4/unsp chr kdny, Chronic kidney disease, unspecified, Athscl
heart disease of native coronary artery w/o ang pctrs, Benign prostatic hyperplasia without lower urinry
tract symp, Primary osteoarthritis, unspecified shoulder, Gout, unspecified, Morbid (severe) obesity due
to excess calories, Long term (current) use of aspirin, Body mass index [BMI] 40.0-44.9, adult

Medications

ASPIRIN/CARVEDILOL

METAMUCIL (oral powder for reconstitution)-laxative

ORDERS AND TREATMENTS

***************PHYSICIAN'S SIGNATURE ON PAGE ONE WILL COVER ALL PAGES OF THIS FORM
485/PLAN OF CARE***************
The patient is recertified to Egida Home Health Care for the episode: 07/25/2023-09/22/2023.

SN frequency: 3w9
Lab Work per MD order 
Emergency contact: Lee, Angela; Relationship: Caregiver; Tel no.: (310)872-9317
RECERTIFIED for comprehensive skilled nursing assessment, observation, and evaluation of
cardiovascular, metabolic, musculoskeletal, neurosensory, pain, gastrointestinal, genito-urinary,
mental/emotional, and integumentary status; assess/monitor nutrition, hydration/elimination,
pain/comfort status, environmental/home safety and knowledge/compliance to prescribed
medications/treatment regimen.
SN TO PERFORM EVERY VISIT:
1. Obtain/Assess Vital Signs: TPR, BP; self-care task, all body system, and functional limitations.
2. Assess for the presence, existence of, and history of risk factors such as Venous insufficiency (chronic)
(peripheral), Non-prs chr ulc unsp prt of l low leg w fat layer exposed, Hypertensive chronic kidney
disease w stg 1-4/unsp chr kdny, Chronic kidney disease, unspecified, Athscl heart disease of native
coronary artery w/o ang pctrs, Benign prostatic hyperplasia without lower urinry tract symp, Primary
osteoarthritis, unspecified shoulder, Gout, unspecified, Morbid (severe) obesity due to excess calories,
Long term (current) use of aspirin, Body mass index [BMI] 40.0-44.9, adult.
3. SN to assess the risk of Emergency Department admission such as UTI, URI, or Fall with an injury.
4. SN to assess risk Re- hospitalization such as: currently taking 5 or more medications, non-compliance
with medication regimen, and home safety risk.
5. Assess joints for swelling, stiffness, redness, pain, and rigidity.
6. SN to assess and report any signs/symptoms of wound deterioration including infection or any
significant changes.
7. Pain scale (0-10), implement pain relief measures and evaluate the effectiveness of interventions.
8. Observe fall prevention/environmental safety, proper hygiene, good peri-care (always keep skin clean
and dry) to avoid skin breakdown, infection control measures, universal precautions, emergency
preparedness, Covid-19 precautions/screening, and proper activation of ER/911.
9. Review new, changed, or discontinued medication since the last MD visit.
SN TO PERFORM/ADMINISTER TEACH TRAIN PT/PCG: 

1. Perform/demonstrate/instruct and validate pcg's ability to perform wound care aseptically to

left lower leg at each visit as follows: Cleanse wound with wound cleanser, pat dry, apply with
collagen dry form, unna boot multi compression dressing, cover with abdominal pad, roll gauze
+tape, coban, change dressing every 2 days as needed for loss of soiling.

SN TO TEACH / VALIDATE PATIENT/ PCG:

1. The disease process of Venous insufficiency (chronic) (peripheral) signs/symptoms such as
swollen feet due to edema, pain aggravated by standing, leg cramps, thickening of the skin
around the ankles, varicose veins, itching, and throbbing of legs. Instruct the Patient/Caregiver
(ANGELA) on compliance with medication and lifestyle change as this is the first method of
treatment. These include Leg elevation, lifting your legs above the level of your heart can help
 reduce pressure in your leg veins. Exercise, walking, and other forms of exercise can help blood
flow better in your leg veins. Weight management, extra weight can put pressure on your veins
and damage the valves.
2. The disease processes of non-pressure chronic ulcer part of the low leg with fat layer exposed,
medications used, actions, and potential side effects; other reportable signs/symptoms of
swelling, burning, itching, skin discoloration, redness, dry, scaly skin and returns/or any
significant change in patient's condition to the physician.
3. The disease process of hypertensive chronic kidney disease with stage 1 through stage 4 chronic
kidney disease and Atherosclerotic heart disease of native coronary artery without angina
pectoris, such as chest pain, shortness of breath, palpitations, dizziness, fainting, stroke, and
sudden cardiac death. Instruct the Patient/Caregiver (ANGELA) on maintaining a healthy diet
accompanied by healthy exercise, limiting the intake of dairy products made with whole milk to
reduce saturated fats, limiting fried food, using healthy oils such as vegetable oil, and being
compliant with prescribed medications.
4. The disease process of chronic kidney disease, signs/symptoms such as edema, kidney pain felt
in the back, and urination changes Instruct the Patient/Caregiver (ANGELA) on lifestyle
modification such as physical activity and renal diet, instruct the patient to keep perineal area
clean and maintain good hygiene to reduce the risk of infection. Instruct to report a significant
change in the patient's condition to the physician.
5. The disease process of Benign prostatic hyperplasia without lower urinary tract symptoms,
signs/symptoms such as urgency to urinate, straining, and dribbling of urine. Instruct the
Patient/Caregiver (ANGELA) on Tamsulosin medication. Tamsulosin works by relaxing bladder
neck muscles and muscle fibers in the prostate itself and making it easier to urinate, take this
medication at bedtime to avoid becoming sleepy during the day. This medication may also cause
you to become dizzy when standing up from a sitting or lying position.
6. The disease process of Primary osteoarthritis, unspecified shoulder, and Gout signs /symptoms
such as joint pain, stiffness, and tenderness of the joint. Instruct the patient/caregiver (ANGELA)
on proper/ timely administration of pain medications and alternative pain management such as
deep breathing exercises and relaxation techniques/energy conservation techniques; encourage
optimal tolerable physical mobility; proper use of the assistive device (walker/Wheelchair);
report pain levels 6/10 or greater to skilled nurse/ physician and other reportable
signs/symptoms or any significant change in patient's condition to the physician.
7. The disease process of obesity, for signs/symptoms such as inappropriate behaviors and
consequences associated with overeating or weight gain and other reportable signs/symptoms
or any significant change in the patient's condition to the physician. Instruct the
patient/caregiver (ANGELA) management such as changing your habits, healthy eating plan,
regular physical activity, and weight-management programs.
8. Pain management: pharmacological/non-pharmacological pain relief measures such as
relaxation, energy conservation techniques, deep breathing exercises, repositioning, and
diversional activities.
9. Diet and medication management; medication’s actions/potential adverse reaction and
compliance.
10. Energy conservation measures include rest periods, small frequent meals, avoiding large
meals/overeating, and controlling stress.
11. Identification of signs and symptoms to observe, potential complications and importance of
prompt reporting to PCP, home safety, fall precautions, Covid-19 precautions/screening, 911/ER
protocol.
 12. Educated Patient to have the following ready: cases of water, flashlights, portable radio, extra
batteries, fire extinguisher, blankets, canned foods, cellphones, and non-perishable foods.
Patient educated and verbal understanding to keep all the mentioned in a low and reachable
location.

SN TO REPORT TO PMD THE FOLLOWING PARAMETERS:

 1. Severe joint pain with a scale greater than 6/10 not relieved with pain relief measures.
2. Fall/injury, episode of ER visit/ hospitalization occurrence, sudden change in mental status; the
presence of edema, s/s of bleeding, chest pain, severe SOB; any significant changes in patientÂ’s
condition. Oxygen saturation reading below 94% (at room air). Weight gain/loss of more than 5 lbs in a
week. S/s of COVID-19.
3. BP greater than 160mmHg/90mmHg or lesser than 90mmHg/60mmHg, with s/sx of HHD crisis,
episode of chest pain/palpitation not relieved with current medications.
4. S/sx of bleeding related to Aspirin regimen.
5. HR lower than 60beats/min or above 100 beats/min; presence of edema; Temp greater than 101F or
less than 96.0F; respiration less than 14 breaths/min or greater than 24breaths/min
6. Fall/injury, episode of ER visit/ hospitalization occurrence, sudden change in mental status; the
presence of edema, s/s of bleeding, chest pain, severe SOB; any significant changes in patient’s
condition.
7. Deterioration of wound status or signs/symptoms of infection

GOALS AND MEASURABLE OUTCOMES

1. The patient will be able to determine therapeutic lifestyle changes such as eating a healthy diet,
exercising, and pharmacologic management of Venous insufficiency (chronic) (peripheral) in 2-3
weeks.

2. The patient will exhibit a stable/improved integumentary status as evidenced by proper

healing of wound on left lower leg and no infection/complications and the Caregiver
(ANGELA) will verbalize understanding and demonstrate safe effective wound care:
supply management/dressing change/disposal of soiled dressings/monitoring for
infection and signs/symptoms to report in 4-5 weeks.
3. The patient will exhibit a stable cardiovascular status as evidenced by no BP less than 90/60
mmHg or greater than 160/90 mmHg, no irregular heart rate less than 60/ minute or greater
than 100/ minute, no signs/symptoms of hypo/hypertension, Hypertensive Chronic kidney
diseases with stage 1-4/ Atherosclerotic heart disease of native coronary artery without angina
pectoris such as SOB or dyspnea, chest pain, dizziness, heart palpitation, and nausea; no
increasing SOB/ dyspnea on exertion/rest and without any complications. The Patient/Caregiver
(ANGELA) verbalizes understanding of the importance of medication compliance and daily BP
monitoring in 6-9 weeks.
4. The patient’s genitourinary status related to Chronic kidney disease will be stable as evidenced
by no increased signs and symptoms such as edema, kidney pain felt in the back, and urination
changes within 5-7 weeks.
5. The patient will remain free from signs/symptoms of exacerbation/complications of Benign
prostatic hyperplasia without lower urinary tract symptoms as evidenced by no signs/symptoms
of urgency to urinate, straining, or dribbling of urine. The patient/caregiver (ANGELA) will
verbalize understanding regarding Tamsulosin medication within 4-6 weeks.
 6. The patient will exhibit an improved/stable musculoskeletal status as evidenced by pain in the
affected area is 0-2/10 on a scale of 0-10 or being at an acceptable level for the patient and well-
controlled by medications/rest, increased tolerance to activities, reduction in weakness/ fatigue,
improved balance/ coordination, demonstrate proper body mechanics, will not manifest any
non-verbal pain cues such as grimacing, moaning and guarding on pain areas, ambulates safely
with proper use of the assistive device and be free from any falls or injury within 4-6 weeks.
7. The patient's metabolic status related to obesity will be stable as evidenced by inappropriate
behaviors and consequences associated with overeating or weight gain within 4-6 weeks.
8. Patient/caregiver will verbalize understanding of the prescribed diet/medications, reportable
s/sx to M.D; s/sx of the disease process, possible complications, and home management of the
above medical conditions during home health episode. 
9. The patient's current medical condition will be stabilized, will remain safe at home, with no
falls/injuries/hospitalization, and will be able to cope with current changes in medical condition
during home health episodes.
10. Patient /caregiver (ANGELA) verbalized understanding regarding COVID-19 precautions and
when to call the MD within 5 weeks.
11. Patient/caregiver (ANGELA) will verbalize/demonstrate knowledge and understanding regarding
avoidance of stress/tension; the importance of exercise as tolerated; energy conservation and
911 protocol in case of emergency within 4 weeks.

PATIENT'S PERSONAL GOALS:

Pcg communicates any specific information about a personal goal(s) the patient would like to achieve
from this home health admission.
- "I want my wound to be healed.”
Compliant with medication and lifestyle change.