Home Health Documentation

Patient Information and Visit Details

Arthur Pendelton (DOB: 14/05/1946, IHI: 8003608166690503), a 78-year-old male residing with his wife at 42 Jacaranda Ave, Chermside QLD, was seen on 24/10/2023 at 09:30 AEST for an initial home health NP assessment. He was referred by the Prince Charles Hospital discharge team following a 5-day admission for an acute infective exacerbation of COPD and decompensated HFrEF, with the primary purpose of this visit being post-discharge medication reconciliation, fluid status review, and chronic disease management.

Initial Assessment and Health Status

The patient was alert and oriented x3, sitting upright in a recliner with mild SOB on exertion when transferring. He mobilises independently over short distances using a 4-wheeled walker (4WW) with a slow, steady gait. His mood is euthymic, speech is clear in full sentences at rest, and he reports 0/10 pain, though his primary immediate concern is persistent bilateral ankle swelling and fatigue.

Vital Signs and Observations

Vital signs recorded at 09:45 were Temp 36.6 °C, HR 78 bpm (irregularly irregular), RR 20 breaths/min, BP 134/78 mmHg sitting, SpO2 93 % on room air, and pain score 0/10. On examination, the patient appeared comfortable at rest with no accessory muscle use, chest auscultation revealed decreased air entry throughout with scattered bibasal fine crackles and no wheeze, and cardiovascular exam showed dual heart sounds with no murmurs and 1+ pitting oedema to the mid-shins bilaterally.

Current Medications and Adherence

Current medications were reconciled against the hospital discharge summary and include furosemide (Lasix®) 40 mg PO OD, bisoprolol 5 mg PO OD, apixaban (Eliquis®) 5 mg PO BD, empagliflozin (Jardiance®) 10 mg PO OD, tiotropium (Spiriva®) 18 mcg INH OD, and salbutamol (Ventolin®) 100 mcg INH PRN. A discrepancy was noted as the patient had been taking his pre-admission furosemide dose of 20 mg PO OD instead of the increased 40 mg dose due to confusion over the new Webster-pak, which his wife assists him in managing.

Care Plan and Treatment Goals

The short-term goal is to achieve eirvolaemia and reduce lower limb oedema from 1+ to trace within 7 days by adhering to the prescribed furosemide regimen and a 1,500 mL daily fluid restriction. Long-term goals include preventing hospital readmission over the next 90 days through daily weight monitoring (maintaining dry weight of 76 kg ± 1.5 kg) and improving exercise tolerance to walk 50 metres without dyspnoea within 4 weeks.

Interventions Provided During Visit

Interventions included cardiopulmonary auscultation, peripheral oedema assessment, formal medication reconciliation, and removal of the outdated furosemide 20 mg packaging from the home to prevent further dosing errors. A daily weight and fluid balance chart was established and placed in the kitchen, and inhaler technique was observed and corrected using a spacer.

Patient and Caregiver Education

Education was provided to the patient and his wife regarding the updated furosemide 40 mg dosing schedule, adherence to a 1,500 mL fluid restriction, low-sodium dietary choices, and heart failure red-flag symptoms (weight gain > 2 kg in 2 days, worsening orthopnoea, or increased ankle swelling). Both demonstrated clear understanding via teach-back and agreed to contact the home health team or GP if weight thresholds are exceeded.

Response to Treatment and Progress

The patient is clinically stable post-discharge with resolving respiratory symptoms, though mild fluid overload persists secondary to the initial diuretic under-dosing. Both the patient and his wife expressed relief after clarifying the medication regimen and demonstrated good engagement with the self-monitoring tools provided.

Safety and Environment Assessment

The single-story residence is clean, well-lit, and clutter-free, with grab rails installed in the bathroom and a shower chair in situ. The patient utilizes his 4WW appropriately indoors, his wife is healthy and available 24/7 for support, and there are no immediate environmental hazards or signs of neglect, keeping his overall falls risk moderate but well-managed.

Coordination of Care and Communication

An update was communicated via secure message to the patient's GP, Dr. Sarah Jenkins, detailing the post-discharge assessment findings, the resolved furosemide dosing discrepancy, and the baseline dry weight of 77.2 kg recorded today. A referral was also initiated for community physiotherapy to assist with pulmonary rehabilitation and home exercise progression.

Plan for Next Visit or Follow-Up

A follow-up home health RN visit is scheduled for 27/10/2023 at 10:00 to reassess fluid status, check U&Es following the diuretic adjustment, and review the daily weight log. The NP will review the patient again in 14 days, with ongoing monitoring of SpO2, respiratory status, and medication adherence required at each interim nursing visit.

Clinician Signature and Credentials

Electronically signed by: Liam O'Connor, NP, Credentialed Nurse Practitioner (AHPRA: NMW0001849201) on 24/10/2023 at 10:30 AEST.