General Update #176 - October 1, 2020
September 30 (addendum)
5:15 p.m. - Jay (Kindred PT) called Dusty back and scheduled his arrival for PT work with Joyce on October 1 between 1:45 p.m. and 2 p.m. Dusty confirmed and would get it onto Joyce's schedule for the day.
5:22 p.m. - Wendy (Dr. Collins' assistant at Moscow Medical) contacted Dusty via phone and informed him that she had spoken with Dr. Collins about updating Joyce's metformin medication away from the "regular" version to the "extended release" version and this should help mitigate the loose stool/diarrhea Joyce has been experiencing. The updated prescription has been submitted to Joyce's pharmacy for fulfillment (the Moscow Walmart pharmacy). Dr. Collins will review the medication change and check on Joyce's bowel movement history with Dusty tomorrow at Joyce's appointment.
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October 1
Dusty arrived to farmhouse ~8:40 a.m. after picking up supplies for farmhouse from Walmart and Walgreens (Hygienic wipes, bananas, eggs, diapers, fabric softener, barrier cream, kleenex). Found Joyce awake, sitting hunched over in her recliner without oxygen line in place. Joyce was a little slow to respond to interrogatives but reported that she was "still trying to wake up" and had "only recently taken the oxygen off."
8:45 a.m. - Bathroom trip. Urinary incontinence occurred sometime during night/early morning hours requiring change of disposable pad on recliner. Joyce was able to rise and walk to bathroom under her own power with some difficulty. Joyce's skirt, diaper, and diaper pad insert replaced. Joyce passed urine and minor Type 5 bowel movement.
Derik arrived into farmhouse to use bathroom but waited as he realized bathroom was engaged. First Step Internet technician from Moscow arrived to farmhouse front door looking for Derik while Dusty was assisting with cleaning Joyce's wounds and applying fresh barrier cream. Derik moved to talk with First Step Internet technician while Dusty returned to caring for Joyce.
Joyce heard conversation from hallway and asked Dusty why First Step Internet was here as she was not aware her Internet was having trouble. Dusty explained to Joyce that Derik was having First Step Internet install wireless internet for him up at her shop. Joyce asked why they were installing it at the shop because she already had internet at the house and she was not going up to the shop. Dusty explained that Derik was having it setup as he was moving into her shop up behind the garden. Joyce became concerned about this occurring as she did not recall approving this to happen either. Joyce did not want the second wireless setup charged to her. Dusty assured her that Derik told him he was going to pay for it separately. Joyce asked why Derik was having wireless internet setup in the shop and Dusty reminded Joyce that Derik has been living up in her garden in a borrowed camper trailer. Joyce became irritated and asked if Dusty approved that because she did not. Dusty reminded Joyce that they had this conversation before and that it was an arrangement Craig had worked out with Derik. Joyce asked if Craig had talked with her about this and if it was something she had forgotten because she does not like this information (Derik living at the farm), and Dusty informed her he did not know because he was not involved in the arrangement as it was something Craig and Derik worked out. Joyce asked Dusty why he allowed this to happen and Dusty informed her he did not approve of this situation but was not involved in the setup of the arrangement. Joyce became concerned that people were taking advantage of her because she was getting old and they thought that they could just get away with things without asking her. Dusty attempted to change the subject to discussion of their overall plans for the day in attempt to calm Joyce down. Joyce became concerned about having to see Dr. Collins, have PT, and potentially shower all in one day. Dusty negotiated moving the shower to tomorrow and that seemed to appease Joyce. Dusty suggested they could do an Epsom salt foot soak once they returned from the farmhouse and that idea sounded good to Joyce. Joyce declined a PT walk after toileting, citing pains in her legs and doubts about being able to remain upright and stable for a prolonged period of time.
9:21 a.m. - Vitals taken. BP 151/78, pulse 88. BGL 139.
9:25 a.m. - Breakfast (1 hard boiled egg, 1 slice wheat toast with butter, remaining vanilla Ensure from last night). Morning medication (Carvedilol, Metformin, 2 Tylenol, Multivitamin, Iron, Potassium). Dusty sanitized toilet riser and sink.
9:28 a.m. - Derik returned to use farmhouse to use bathroom and departed after use.
Dusty had to keep after Joyce to eat so they could remain on schedule for making their morning appointment at Moscow Medical. Joyce insisted she was not hungry. Dusty encouraged her to eat as she needed food to be in her stomach for her medication to work.
Joyce finished her breakfast ~10:20 a.m. Joyce semi-disoriented/confused and lethargic. Joyce could not recall what the plans were for he day and asked Dusty what they were going to be doing. Dusty reminded her of plans to get her ready to get into town for appointment with Dr. Collins and PT.
10:45 a.m. - Bathroom trip. Urinary incontinence requiring change of skirt and replacement of diaper and diaper pad insert. Joyce became irritated with Dusty about toileting. Joyce calmed when Dusty assured her that the bodily functions were not her fault but a result of age and that everyone would be there one day.
~11 a.m. Joyce loaded into car with some difficulty (Joyce kept wanting to look at her patio and flower pots and Dusty had to remind her to focus on getting into the Subaru; Joyce had difficulty in seating herself down onto the Subaru's passenger chair and then manipulating her lower extremities into place without assistance due to poor coordination). Dusty promised Joyce they could try getting outside tomorrow when they were not on a timeline to be somewhere else when she expressed dissatisfaction with Dusty about not her being allowed to look at her patio.
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11:20 a.m. appointment with Dr. Collins at Moscow Medical. Joyce had extreme difficulty in traveling from car and into Moscow Medical using her walker. Extremely fatigued by the time she reached the examination room.
Dr. Collins' assistant, Wendy, took Joyce's vitals and reviewed items to be discussed with Dr. Collins:
- Insulin (if Joyce has to return to it or if the metformin increase has been sufficient)
- Diarrhea/loose bowel movements
- Left knee mobility issues and pain flare ups
- New wheelchair order
- Canker sores/wounds in Joyce's mouth (thrush?)
- Paperwork/documentation for hospice care and if Joyce could qualify for it as it would be covered by Medicaare
- Options for in-home care and paperwork that Dusty could get from Dr. Collins in advance so he has it ready to go when approaching one of their services if needed (or proper processes to undertake, if any, that would involve Dr. Collins' office)
- Dusty's FMLA paperwork and documentation from Dr. Collins for UI's Human Resources office
Both Wendy and Dr. Collins reviewed the logbook data Joyce's family has been keeping. Family encouraged to continue documenting Joyce's blood sugar levels, blood pressure, urine output/bowel movements, and weight in the logbook. Confirmed Kindred's recommendations on monitoring Joyce's weight range to ensure Joyce is not getting water built up around her heart. Confirmed that Kindred PT is arriving two times per week to work with Joyce. Dusty reported that Joyce is not meeting all the PT and OT goals each week due to fatigue, leg immobility, etc.
Blood sugar levels ~130 is good, no need to return Joyce to insulin use at this time. Plan to continue on with 1000mg of metformin. Low sodium and low sugar diets should continue on as family has been doing, appears to be working well for Joyce.
Joyce's diarrhea issues were reviewed. If diarrhea only lasted one to two weeks after leaving Aspen Park, it could have been an issue with dietary change to home foods or increased movement around the home. Dusty clarified that Joyce does not walk much around her home. Dr. Collins believes is most likely a result of the current version of metformin being administered and not a virus or infection (virus or infection would have Joyce having issues with diarrhea several times within an hour instead of 2-3 times per day). Joyce not reporting aches or pains in her intestines or stomach area. No noted diarrhea incidents in Joyce's records from Aspen Park. Timeline for increased metformin dosage matches diarrhea timelines family has logged. Orders were submitted to the Walmart pharmacy in Moscow for the extended release version of metformin which Joyce should be switched to going forward. Dusty confirmed that he would pick it up today and start her on it with this evening's meal. Dr. Collins recommends giving the new extended release metformin 2 weeks before family adds anti-diarrhea or fiber supplement to Joyce's diet (checking in with Dr. Collins first).
Dusty confirmed that Joyce has suffered no falls since returning to the farmhouse.
Joyce's left knee was inspected by Dr. Collins, no excessive fluid around the joint was noticed. Dr. Collins is suspecting that arthritis in the knee is the culprit for the pain and inability to move the leg Joyce is experiencing. Dr. Collins will contact Kindred's physical therapy team to add some exercises for the left knee and to change what they may be currently doing that could be causing aggravation to the joint. If the knee continues to cause Joyce pain or its condition or her mobility continues to deteriorate then an X-ray and/or steroid shots may be ordered by Dr. Collins on or before the next follow up appointment.
Dr. Collins believes a new wheel chair for Joyce would be a good idea, given intermittent immobility Joyce has been experiencing and for use in moving Joyce from car to other appointments in the future. Dr. Collins will submit the orders for a wheelchair for Joyce to Northwest Respiratory for fulfillment. NW Respiratory will contact Dusty to coordinate wheelchair selection and insurance coverage information.
Dr. Collins inspected the sores in Joyce's mouth confirmed not to be Thrush. Recommended that family give Joyce a saltwater mouthwash to swish and spit out after meals and before bedtime. Dr. Collins suspects that Joyce may need to see the dentist to have her teeth dealt with and ensure her upper dentures are still fitting correctly as they might be the cause of the sores in Joyce's mouth. Dr. Collins reviewed Joyce's dietary log and didn't find anything listed that would cause the sores.
Dialogue about in-home care options, Dusty's UI FMLA paperwork, and potential documentation and other processes needed to be initiated for potential hospice care for Joyce. Collins departed temporarily from the examination room to retrieve a print out of material she created for Dusty back in her office.
While Dr. Collins and Wendy were out of the examination room, Joyce had become agitated and confronted Dusty about what he had been speaking with Dr. Collins relating to her life, expressing that it sounded like he was trying to get Dr. Collins to place Joyce "in a home." Dusty clarified that he was asking for information about Hospice care for Joyce for in-home care as he was told he could not be out at the farmhouse during the business hours of a day as he had been doing. Joyce asked what the hospice talk was about as she thought that translated to going back to Aspen park. Dusty clarified that hospice is covered by Medicare while in-home care is not, and the family cannot afford in-home care for 8 hours a day for the next few years so hospice would be a better option. Joyce was calmed but stated that she wanted to talk more about this as she doesn't understand everything Dusty said to her and is confused about what is being discussed about her.
Dr. Collins returned to examination room and reviewed options for caregiving for Joyce with Dusty. Dr. Collins confirmed that Joyce would most likely be able to qualify for hospice care and would submit referral for an evaluation to be conducted on Joyce. Someone should be in touch with Dusty to schedule an appointment. Dr. Collins reviewed the in-home caregiver options that Aspen Park and the University of Idaho Employee Assistance Program provided to Dusty to contact. Dr. Collins noted that in-home caregiving options are not covered by Medicare but that Hospice would be. If the only option to get Joyce and her family through November through January (or beyond if needed) is in-home care then the recommendation from Dr. Collins and Wendy was Family Resource Home Care. Dr. Collins provided a list of recommendations as well and Dusty will reach out to the ones identified that he has not so far to finalize his list for the family to review at their next family meeting.
Wendy assisted Dusty in returning Joyce to Joyce's Subaru out in the parking lot using one of Moscow Medical's wheelchairs as Joyce stated she was unable to walk.
Dr. Collins was pleased that Joyce was able to return home, was glad to hear that the family was so involved in Joyce's care, and that Joyce appeared to be doing well.
Dusty to call Moscow Medical to schedule December follow-up appointment with Dr. Collins for Joyce.
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Dusty took Joyce's walker to NW Respiratory for brake repair. Technicians were able to repair brake lines but noted next time they would have to look at replacing the brake shoes and possibly the wheels as both appeared to have some regular and irregular wearing that has reduced their life span. As Joyce's walker was purchased so long ago it is no longer in the NW Respiratory system so its maintenance log was added to Dusty's NW Respiratory account (but noted that it belongs to Joyce and not to Dusty, so is separated from is CPAP and nebulizer account).
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Dusty and Joyce attempted to reach the Walmart pharmacy before it closed for lunch hour but due to traffic were not able to make it in time. Dusty will travel to Walmart again after Joyce's lunch and PT appointment. Joyce had Dusty purchase some small cans of Pepsi for her (Diet and Zero sugar varieties) which she wanted to try to "help perk her up."
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1:50 p.m. - Dusty and Joyce returned to farmhouse. Joyce had extreme difficulty in getting up onto the patio step's landing, requiring assistance from Dusty to figure out how to lift her legs to step up and then had to be steadied when she started to topple backward into Dusty. Joyce was taken to bathroom without incident (diaper and diaper pad clean). Joyce was elated that she had gone through such physical exertions getting into and out of Moscow Medical, waited in the care for a length of time, and got into the farmhouse again without having an accident. Urine and small amount of fecal matter passed with flatus. Brief irritation with Dusty as he Dusty cleaned wounds and applied fresh barrier cream as she stated she was hungry and irritable and had no patience because she had a long day, was tired, had to go see Dr. Collins and talk about having alternate caregivers instead of Dusty which upset her. Dusty and Joyce talked through her feelings, Joyce was given reassurance that Dusty would still be helping care for her, and Joyce apologized later on during walk back out to recliner for her "nasty" behavior toward Dusty once her mind was restored and promised lunch was being setup.
2 p.m. - Lunch (1/3 Humble Burger sandwich, 1/2 of fries, 1/8 Diet Pepsi). 2 Tylenol for pain relief.
3:50 p.m. - Joyce given salt water wash for oral wound care. Joyce reported that the first round of salt water swishing helped her with the pain she has been feeling. Joyce asked which person told Dusty to do the saltwater mouth wash for her sores as she could not recall having visited with Dr. Collins today. Dusty informed her it was Dr. Collins and the Kindred nursing team.
4 p.m. - Joyce requested to stretch out and nap as she felt very tired from the day's activities. Dusty assisted her with getting comfortable in her recliner, reviewing all they did (which Joyce did not entirely recall).
Dusty setup Joyce's dinner tray for Connie to use when she arrives to care for Joyce in the evening hours and will depart farmhouse ~4:20 p.m. to return to town to pickup Joyce's new medication from Walmart pharmacy. Joyce stated that she wanted to finish today on the regular medication and switch to the new metformin tomorrow so Dusty will bring it out with him when he returns ~8 a.m. and give it to her with breakfast.
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Jay (Kindred PT) did not arrive to farmhouse today between 1:45 p.m. and 2 p.m. as he had scheduled yesterday. Possible he attempted to arrive ~1:30 p.m. before Joyce and Dusty returned from travel to Moscow.
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