Detailed Home Health Nursing Notes

Patient Information

• Patient Name: Arthur William Pendelton
• Date: 15/05/2026
• Date of Birth: 12/08/1946
• Address: 42 Jacaranda Drive, Chermside, QLD 4032
• Phone Number: 07 3123 4567
• Email Address: a.pendelton46@example.com.au
• Emergency Contact: Margaret Pendelton (Spouse)
• Contact Information: 0412 345 678
• Primary Care Physician: Dr. Priya Sharma
• Contact Information: Chermside Medical Centre, 07 3987 6543
• Insurance Provider: Bupa Health Insurance (Medicare No: 2345 67890 1)
• Policy Number: BUP-8839201

Visit Information

• Date: 15/05/2026
• Start Time: 09:30
• End Time: 10:15
• Location: Patient's residence
• Reason for Visit: Scheduled home health Nurse Practitioner visit for routine assessment of right lower extremity (RLE) venous stasis ulcer, wound dressing change, and chronic heart failure (CCF) fluid status monitoring.

Clinical Assessment

• Blood Pressure: 128/76 mmHg
• Heart Rate: 72 bpm
• Respiratory Rate: 16 breaths/min
• Temperature: 36.7 °C

The patient's vital signs were recorded during the visit. The blood pressure is 128/76 mmHg, which falls within the expected target range for his baseline. The heart rate is regular at 72 bpm, and the respiratory rate is unlaboured at 16 breaths/min, both within normal limits. The tympanic temperature is 36.7 °C, which is afebrile and does not require clinical attention.

Physical Assessment

• General Appearance: The patient is alert, oriented, and sitting comfortably in a recliner in no acute distress. He appears well-groomed with good personal hygiene, maintains an upright posture, and engages cooperatively in conversation.
• Skin Integrity: Skin is warm, dry, and intact globally except for a 2.5 cm x 2.0 cm x 0.2 cm venous stasis ulcer on the right medial malleolus; the wound bed is 80% granulating tissue and 20% slough with moderate serous exudate and no surrounding erythema, and routine wound care was provided.
• Neurological: Alert and oriented to person, place, and time (GCS 15). Gross motor function and coordination are intact, though decreased light touch sensation is noted bilaterally in the feet secondary to known diabetic peripheral neuropathy.
• Musculoskeletal: Decreased range of motion noted in bilateral ankle joints with 4/5 muscle strength in the lower extremities. The patient ambulates with a steady, slightly slow gait using a four-wheeled walker (4WW) for stability.
• Respiratory: Respiratory effort is easy and unlaboured on room air. Auscultation reveals clear breath sounds throughout all lung fields without wheezing, crackles, or dyspnoea.
• Cardiovascular: Heart sounds S1 and S2 are dual with a regular rate and rhythm and no murmurs. Dorsalis pedis and posterior tibial pulses are 1+ bilaterally, capillary refill is approximately 2 seconds, and 1+ pitting oedema is present in the bilateral lower extremities to the mid-shin, without cyanosis.
• Gastrointestinal: The abdomen is soft and non-distended with normoactive bowel sounds present in all four quadrants. The patient reports a good appetite and regular daily bowel movements, denying any nausea, vomiting, or constipation.
• Genitourinary: The patient voids freely without incontinence or an indwelling catheter. He reports increased urinary frequency following his morning diuretic dose, denying any dysuria, haematuria, or suprapubic pain.

Medical Management

• Medications: Current regular medications include furosemide (Lasix®) 40 mg PO daily, bisoprolol (Bicor®) 5 mg PO daily, ramipril (Tritace®) 5 mg PO daily, metformin (Diabex®) 1,000 mg PO BID, and paracetamol (Panadol®) 1,000 mg PO QID PRN. Medication reconciliation via Webster-pak confirmed 100% adherence with no discrepancies identified.
• Medication Administration: Paracetamol (Panadol®) 1,000 mg PO was administered once at 09:35 prior to the wound dressing change for prophylactic analgesia; the patient tolerated the medication well without adverse effects, and pain remained well-controlled throughout the procedure.

Interventions

• Interventions: Performed aseptic wound care to the RLE medial malleolus ulcer, cleansing the wound bed with 0.9% normal saline, performing light mechanical debridement of loose slough with gauze, applying barrier cream to the periwound skin, dressing the ulcer with cadexomer iodine (Iodosorb®) ointment and a foam adhesive dressing, and applying a two-layer compression bandage system from the base of the toes to below the knee. Point-of-care capillary blood glucose (BGL) was checked and measured 7.4 mmol/L.
• Reaction/s: The patient tolerated the dressing change and compression wrapping well, reporting a brief pain score of 2/10 during cleansing which resolved immediately afterward, with no adverse reactions observed.

Care Plan

• Current Care Plan: The current care plan focuses on promoting complete epithelialisation of the RLE venous ulcer through twice-weekly aseptic dressing changes and compression therapy, alongside daily weight and oedema monitoring to prevent CCF exacerbations. Ongoing support includes diabetic glycaemic tracking and fall prevention strategies within the home environment.
• Updates: Continue the current wound care regimen as the ulcer size has decreased by 0.3 cm since last week; added a referral to the community podiatry service for routine diabetic foot and nail care.

Patient Education

• Topics Discussed: Discussed the importance of elevating the lower legs above heart level when resting, maintaining a low-sodium diet (< 2,000 mg/day), daily weight monitoring, and red-flag symptoms of wound infection (increased pain, spreading redness, purulent discharge, or fever) and fluid overload (weight gain > 1.5 kg in 2 days or increased SOB).
• Understanding and Compliance: Both the patient and his wife verbalised clear understanding of the instructions, asked appropriate questions regarding compression bandage comfort, and demonstrated the ability to accurately record daily weights in his home diary.

Patient and Caregiver Feedback

• Patient Feedback: The patient expressed satisfaction with the steady healing of his leg ulcer and noted that the pre-procedural paracetamol kept him comfortable, though he mentioned mild itching under the top edge of the compression wrap.
• Caregiver Feedback: Mrs. Pendelton reported that the patient has been compliant with elevating his legs in the afternoons and stated she feels confident managing his medications and diet at home without additional respite support at this stage.

Next Visit Plan

• Date: 19/05/2026
• Time: 09:30
• Goals for the Next Visit: Reassess RLE venous ulcer dimensions and wound bed tissue, perform routine dressing and compression bandage change, review the patient's daily weight log, and evaluate cardiopulmonary status.

Provider’s Name and Signature

• Provider’s Name and Signature: Liam O'Connor, NP (Electronically signed by Liam O'Connor, Nurse Practitioner, AHPRA: NMW0001928374)
• Date: 15/05/2026