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Related to CKD, poor hygiene, increased urination from CHF, and incontinence from poor mobility

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Currently mobilizing min A x 1 w/2WW. Min-moderate general weakness to LE bilaterally. Right UE significant limited ROM (less than 45 degrees for shoulders) and strength. (Housing is cluttered, Poor activity tolerance secondary to edema – pt does not wear her compression socks). Pt is not able to get into the shower, has been taking sink baths

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She reported that she usually wears slip on shoes with no socks in apt and facility and only wears shoes when she goes out and someone is always with her then to help due to inability to bend over or reach feet, stockings are also torn (relates to not wearing socks). Hygiene inadequate, noticeable body odour and build-up of exudate under her breasts, evidence of skin breakdown as unable to get into shower (relates to mobility, unable to lift shoulder above 46 degrees). Home is cluttered, making navigation hard, pt unable to clean living area herself. Clara has chronic UTI’s and frequent urination with UTI’s. Clara also has elevated BGL (10.1 random glucose, 12.1 A1C)

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Loss of sensation to lower extremities, specifically her (R) big toe. Denies elevating her legs or wearing her compression stockings. Poor vision makes navigation diffucult

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Has suffered the loss of her husband (10 years ago) and Son, Dwight. Also has a strained relationship with her other two children and likely has grief over the loss of significant relationship

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Pt is primarily alone, stating "I rarely have anyone to talk to". C.P. seems depressed with a flat affect and expressions of sadness. However, she seemed to perk up with visits. Subsequently been diagnosed with depression. Prescribed citalopram 20mg PO OD

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Pt is spiritual and attends the cultural center every Wednesday. Pt has lost the ability to speak Cree but can understand it. Pt asked for a consult with spiritual and cultural care on Jan 2 admission, no clinical documentation on whether consultation occurred. Clara was in residential schools but is reluctant to discuss.

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Able to ambulate with a 2ww/4ww if short distances. Improvements can be made to encourage continuation of ambulation and improvement of distance to facilitate improved ADLs

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Aware she needs extra help around her home and with her health but is also aware that she is stubborn and resistant

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C.P. is at risk for decreased motivation for improvement as she may not see the benefit to improving her health over the disparity of her illnesses

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Pt receiving daily homecare. Decreased risk of medication error, increased Hygiene, and socialization

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Able to connect with her culture and socialize

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Pt often forgets to take her meds. She also is not sure what she is taking, this could result in med errors/poor outcomes for health.

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Primary support person is not often available

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C.P. fears she will fall, resulting in a fracture. Decreases ambulation to avoid falling. Decreasing ADLs and socialization