2402 Wayne Memorial Drive, Goldsboro NC 27534-1728, (919) 735-1387

485 Worksheet Addendum Hospice

Patient Name: DOB: Patient ID: Office: Visit Frequency: Certification: Recertification:

HOSPICE ORDERS  SKILLED NURSING  ADMIT TO HOSPICE. PATIENT LIFE EXPECTANCY IS 6 MONTHS OR LESS IF THE TERMINAL ILLNESS RUNS ITS COURSE.  NO CODE.  FULL CODE.  TEACH HOSPICE CONCEPTS. 24 HOURS HOSPICE CARE AND SUPPORT.  OMIT MD NOTIFICATION OF ABNORMAL VITAL SIGNS RELATED TO DETERIORATION.  ASSESS AND TEACH SIGNS AND SYMPTOMS OF DETERIORATION AND DYING PROCESS.  ASSESS AND TEACH SIGNS AND SYMPTOMS OF CONSTIPATION.  ASSESS AND TEACH USE OF LAXATIVES OR ENEMA FOR CONSTIPATION AND/OR FECAL IMPACTION  CHECK AND OR REMOVE IMPACTION.  ASSESS AND TEACH NEW OR CHANGED MEDS ADMISSION TO DISCHARGE.  MAY WITHHOLD MEDS PRN BASED ON PATIENT DETERIORATION STATUS.  MAY USE CONDOM CATH FOR URINARY INCONTINENCE  MAY USE FOLEY 16FR 5CC FOR INCONTINENCE.  IF FOLEY UTILIZED, CHANGE FOLEY CATH Q MONTH AND 4 PRN IF OCCLUSION OR LEAKAGE.  ENCOURAGE PATIENT TO PARTICIPATE IN PLAN OF CARE.  ENCOURAGE CAREGIVER TO ASSIST WITH PATIENT CARE AS DESIRED.  PROVIDE EMOTIONAL SUPPORT TO PATIENT AND CAREGIVER.  PRAISE AND REINFORCE CARE PROVIDED BY CAREGIVER TO THE PATIENT.  RN TO ASSESS PATIENT EVERY VISIT AND PRN FOR CHANGE IN CONDITION/PAIN OR SX MANAGEMENT/PROVIDE SUPPORT/NEEDS R/T END OF LIFE.  ASSESS CARDIOPULMONARY HYDRATION ELIMINATION STATUS.  ASSESS SKIN INTEGRITY AND TEACH DECUBITUS PREVENTION.  ASSESS AND TEACH PAIN CONTROL 0 TO 10 SCALE.  RECORD AND REPORT CHANGES TO RN AND MD.  ASSESS AND TEACH SYMPTOM MANAGEMENT.  ASSESS HOME SAFETY.  HOSPICE RN MAY ACT AS AGENT OF PHYSICIAN TO COMMUNICATE PRESCRIPTION ORDERS TO PATIENT’S PHARMACY

485 Worksheet Addendum –Hospice Page 1 rev. 06/09 2402 Wayne Memorial Drive, Goldsboro NC 27534-1728, (919) 735-1387

 AS PATIENT CONDITION WARRANTS MAY INITIATE OXYGEN 2-4L VIA NC PRN SHORTNESS OF BREATH, GEL MATTRESS, HOSPITAL BED, SUCTION, (ETC) HOSPICE GOALS  PATIENT AND OR CAREGIVER WILL BE KNOWLEDGEABLE OF HOSPICE SERVICES IN VISITS.  PATIENT AND OR CAREGIVER WILL VERBALIZE SIGNS AND SYMPTOMS OF DETERIORATION OR DYING IN VISITS.  PATIENT PAIN WILL MAINTAIN AT 0 TO 3 ON 0 TO 10 SCALE.  PATIENT INCONTINENCE WILL BE MAINTAINED WITH GOOD SKIN INTEGRITY.  BOWEL REGIMEN MAINTAINED WITH USE OF LAXATIVES OR ENEMA .  FOLEY CATHETER WILL BE PATENT.  PATIENT AND CAREGIVER WILL BE KNOWLEDGEABLE OF ACTION AND SE OF MEDS FROM ADMISSION TO DC.  PATIENT AND CAREGIVER WILL BE KNOWLEDGEABLE OF HOW TO MAINTAIN GOOD SKIN INTEGRITY AND DECUBITUS PREVENTION IN VISITS  PATIENT AND OR CAREGIVER WILL VERBALIZE USE OF PAIN OR SYMPTOM MANAGEMENT IN VISITS.  PATIENT AND CAREGIVER WILL PARTICIPATE IN PLAN OF CARE.  PATIENT WILL LIVE MEANINGFULLY UNTIL DEATH.  NO DISCHARGE FORESEEN DUE TO TERMINAL ILLNESS.

485 Worksheet Addendum –Hospice Page 2 rev. 06/09