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Chronic Urinary Tract Infections

mrt979 — 2024-02-02 18:11:31 UTC

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

Diabetes Type 2

mrt979 — 2024-02-02 18:13:14 UTC

Osteoarthritis

mrt979 — 2024-02-02 18:13:53 UTC

Depression

mrt979 — 2024-02-02 18:16:21 UTC

Congestive Heart Failure

mrt979 — 2024-02-02 18:18:13 UTC

Difficulty with Memory

mrt979 — 2024-02-02 18:19:03 UTC

Falls

mrt979 — 2024-02-02 18:19:13 UTC

Macular Degeneration

mrt979 — 2024-02-02 18:19:25 UTC

Mobility

mrt979 — 2024-02-02 18:25:49 UTC

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

Comfort

mrt979 — 2024-02-02 18:26:18 UTC

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)

Sensory Perception

mrt979 — 2024-02-02 18:26:46 UTC

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

Grief & Loss

mrt979 — 2024-02-02 18:27:20 UTC

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

Mood and Affect

mrt979 — 2024-02-02 18:27:37 UTC

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

Spirituality

mrt979 — 2024-02-02 18:27:59 UTC

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.

Resilience

mrt979 — 2024-02-02 18:45:53 UTC

Relationship with Nephew

mrt979 — 2024-02-02 18:47:10 UTC

Ambulation

mrt979 — 2024-02-02 18:49:41 UTC

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

Resistance to Help

mrt979 — 2024-02-02 18:51:15 UTC

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

Isolation/Decreased Mood

mrt979 — 2024-02-02 18:54:05 UTC

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

Homecare

mrt979 — 2024-02-02 19:04:42 UTC

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

Indigenous Cultural Center

mrt979 — 2024-02-02 19:07:26 UTC

Able to connect with her culture and socialize

Noncompliance to Medication

mrt979 — 2024-02-02 19:12:42 UTC

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.

Nephew Works

mrt979 — 2024-02-02 19:15:09 UTC

Primary support person is not often available

Fear of Falling

mrt979 — 2024-02-02 19:18:38 UTC

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