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Takes zopiclone

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Difficulty with mobility has impaired Clara's ability to get around on her own, and she is no longer able to dance, which was one of her previous hobbies
Changes in sight have impacted her ability to read, another hobby she enjoyed

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Has gotten lost taking public transport
Limited family support
Transportation arranged once a week to Native Seniors Centre

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Experiences pain in R shoulder
Pain on urination with chronic UTI
Difficulty with mobility, experiences pain, trouble getting places
Unsure what her medications are for, causes her worry and confusion
At times she is unsure which medications manage her pain
Finds relief when using pain meds
Difficulty with personal hygiene r/t pain, limited mobility, memory loss that causes discomfort
Incontinent periodically d/t chronic UTI

Finds comfort in Native Seniors Centre and being around people who speak Cree
Comfort in relationship with nephew
Psychosocial distress r/t strained family relationships, loss of relatives, trauma experienced in residential schools

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Lives alone in assisted living
Has limited interaction with family - only one supportive nephew
Loss of husband and son, strained relationships with children
Main social interaction is visiting Native Seniors Centre once weekly

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Visits Native Centre weekly

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Nephew Daryl lives out of town, but supports Clara when he is able
Expressed concern to Clara's care team that she was not managing meds well at home

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Son Dwight passed away "a few years ago"
Husband passed away in 2005
Reports missing both family members and thinking of them often
Cousin passed away and she was unable to attend burial

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Clara notes having a strained relationship with her 2 surviving children, James and Connie

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Memory Loss/Confusion (Cognitive Impairment) 

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Memory Loss/Confusion (Cognitive Impairment) 

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Feels she "needs a new mind" and has some instances of short and long term memory loss
Has gotten lost after taking public transit recently
Acute confusion r/t UTI

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Residential school survivor
Has persisted through numerous health challenges and losses of culture, family, and independence

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Elevated uric acid levels
Takes allopurinol (antigout agent)
Elevated CRP, WBC indicate inflammation
May cause increased pain

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Clara reports a dull, achy pain that has remained since fracture in 2016
Pain relieved by acetaminophen, naproxen
Impacts mobility

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Takes calcium carbonate (supplement), alendronate (reabsorption), taking calcitriol (vitamin D, promotes reabsorption of calcium)
Increased risk of falls/injury from falls

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High urea, creatinine, ESR (inflammation may be d/t CKD)
Low GFR (70 - indicates mild CKD)
Low specific gravity of urine
Low sodium
Taking calcitriol (indicated in CKD pts who have decreased calcium reabsorption)
Appears she may have anemia r/t CKD
-taking Eprex for this
-is it effective? labs indicate she may be anemic
May impact her sleep

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Takes synthroid
Can lead to muscle weakness
Can cause impaired memory
Sleep disturbances
Increased risk of CHF
Depression
Neuropathy

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May cause low specific gravity of urine
Low sodium
Taking spironolactone (diuretic)
Takes atorvastatin (lipid lowering agent, reduces risk of CAD and MI)

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High blood glucose
Upon d/c, BGM 3x daily for 3 days
Takes metformin

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Taking metoprolol and ramipril (antihypertensives)
Taking spironolactone (diuretic)
Can cause blurred vision/visual disturbances

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Currently taking nitrofurantoin for present UTI
Recent urinalysis indicates cloudy, amber coloured, foul-smelling urine with nitrates and glucose present
High lymphocytes indicate infection/inflammation

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Sense of connectedness to Native Seniors Centre and hearing Cree spoken
Positive relationship with nephew, Daryl
Experienced abuse/loss of culture and language attending residential schools

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Overall has a positive attitude and outlook - great sense of humor
States feeling lonely
Misses family members she has lost in recent years (son, husband, cousin)
Difficulty speaking about trauma she experienced at residential schools
Has experienced depression

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Death of husband and son
Strained relationships with her surviving children
Losing her independence, needing more support with ADLs
Loss of mobility -mentions she used to love dancing but now struggles to get around
Loss of culture through residential schools, surviving intergenerational trauma

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Macular Degeneration (vision loss is a geriatric syndrome)
-Clara does not use glasses, has a magnifying glass to help with reading
Hard of Hearing (hearing loss is a geriatric syndrome)
Decreased sensation to lower extremities, equal bilaterally
-may be related to diabetic neuropathy? May need further assessment

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Uses a walker
Has difficulty walking long distances
Lower extremity weakness on assessment (bilat)
Pain may impact her mobility (Fracture, UTI)
Takes pain medication (naproxen and acetaminophen)- which are effective but she notes she has difficulty with some movements (lifting) d/t pain
Fall risk - impaired cognition, confusion with UTI
Osteoporosis and osteoarthritis - may cause her pain and create more difficulty with mobility
Takes antihypertensives - may increase fall risk if she experiences orthostatic hypotension (common side effect)
Fatigue may impact Clara's mobility as she sleeps poorly at night
Takes zopiclone, may cause daytime drowsiness/dizziness that could impair mobility