General Update #210 - Monday, November 9, 2020 (Updated)

Updated 11/10/2020 to include definition of symptoms that place Joyce in the "Yellow Zone" of Congestive Heart Failure.

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9:15 a.m. - Jess arrived to farmhouse, Craig present. Joyce had just returned from taking herself to the bathroom and reported that she was dry.

9:42 a.m. - Vitals taken, BP 135/78, pulse 84, BGL @ 84.

9:45 a.m. - Breakfast (3 pancakes with butter and syrup), finished breakfast by 10 a.m.

10:09 a.m. - Morning medication with nutritional shake.

10:45 a.m. - Bathroom trip without incident. Passed urine and small bowel movement (type 5). Jess helped get Tiger balm and lidocaine patches applied to Joyce's left knee and back, respectively, before bathroom trip. Dusty arrived to farmhouse.

11:04 a.m. - Compression stockings put onto Joyce. 

11:07 a.m. - Marshall (Kindred PT) arrived to perform the discharge visit. After today there will be no further at home PT work with Joyce from the Kindred team unless ordered by Joyce's primary care physician. Marshall confirmed with Dusty that PT exercises should continue as Joyce is able to perform them based on her stamina and ability. Joyce reported no falls since Marshall's last visit and Marshall reviewed fall prevention measures that should be taken in regard to Joyce (standby assist with everyday living activities by family caregivers - toileting, dressing, meal preparation, etc.). Marshall reviewed Joyce's oxygen flow rate of 2 liters and confirmed use is nearly 24-hours. Vitals were 126/76, pulse 84 when Marshall took them from Joyce during visit. Joyce stated she had no difficulty breathing when asked. Marshall inspected Joyce's legs - continued use of compression stockings, elevation of legs, and movement activity (upright walking or lower leg exercises from seated position) should continue but no significant points of concern raised. Marshall put Joyce through resistance and range of motion exercises for her lower body. No functional decline with muscle strength apparent. Joyce performed a sit/stand exercise off her recliner (5 reps) and family care givers have been directed to add this to Joyce's routine if possible each day to help with Joyce's knees. If Joyce's left knee prohibits this exercise due to pain then skip the exercise for the day. Marshall confirmed there were no occurrences of skin breakdown or open wounds on Joyce, no numbness in her hands or feet reported. Marshall had Joyce go through some mobility exercises as he checked her walking gait, balance, motor control, and stamina (walking, pivoting, maneuvering the walker in tight turns and direction change, toe raises, high marches, etc.). Joyce noted to be slightly unstable in her balance but had good strides overall when in motion. Joyce denied she had trouble walking. Marshall worked with Joyce on her posture, noting how she continues to slump while sitting and standing. Joyce's health data log that the family keeps on her was reviewed with Marshall. Marshall attempted to continue on with more PT exercises but Joyce began to become unfocused, halting an exercise and walking away from Marshall (apparently resetting her mental state and timeframe to earlier in the visit when Marshall had directed her to walk around the room - so Joyce just picked up and continued on from that point in much the same manner she had done the first go around). Marshall departed ~11:27 a.m.

11:44 a.m. - Joyce soiled herself. Dusty assisted with getting her into bathroom and cleaned up.

11:45 a.m. - Debra (Kindred nurse) arrived to farmhouse, directed to wait in kitchen while Dusty cleaned up Joyce. 

Joyce returned to the kitchen ~12:07 p.m. for appointment with Debra. Debra has not been out to care for Joyce before and so had to go through all the confirmation documentation with Joyce and Dusty. Debra confirmed that Joyce has had no incidents of falls (since her fall down the basement stairs in June), has had no hospitalizations since the June accident, wore glasses, used the oxygen at a 2 liter flow rate nearly 24-hours, medications currently being used, has dentures, has some age-related hearing loss (Joyce contested this note), no headaches, confirmed no currently open wounds or pressure sores, and the family caregiver schedule and log book data. 

Debra reviewed pressure sore prevention care with Dusty and he confirmed the family caregivers were following the prescribed plan and all appeared to be well. Joyce's ability to move/shift about under her own power in her recliner was confirmed (and demonstrated by Joyce) which gave confidence that Joyce would not be stuck in an uncomfortable position for hours and be unable to respond to pain stimulus. 

Joyce's breathing was checked, Joyce not reporting issues with breathing but was noted to be out of breath from walking back into kitchen from bathroom. Vitals 104/61, blood oxygen levels at 89%. 

Debra noted Joyce's cancer history and confirmed that as of August Joyce was cancer free. Confirmed follow up appointments with Joyce's primary care physician and oncologist. Confirmed a durable power of attorney was on file for Joyce with the family and at Aspen Park's record holdings. Joyce reported no dizziness when asked, and that she only had leg cramps "when I don't get enough potassium in me." 

Debra reviewed Joyce's diabetic condition, medication, and BGL testing. Debra checked Joyce's feet and encouraged the family caregivers to be mindful of slivers or other damage to the feet which could turn to wounds that Joyce might not be aware of as diabetes can progress and rob an individual of feeling in the flesh of the feet. 

Debra reviewed Joyce's reported pains in shoulder and arms and suggested that it could be from PT work, improper use of walker, changes in use of muscle groups, etc. and family care providers are encouraged to keep track if condition or pain level worsens for Joyce. Left knee pains assumed to be arthritis related, family care givers directed to continue primary care physician's directive of analgesics and topical treatments for pain relief. 

Debra stated that Joyce had congestive heart failure on her records. Dusty asked for clarification and Debra explained that the swelling in Joyce's legs/hypertension were mild heart failure symptoms and so the note in the record was general identification of deterioration rather than something rapidly occurring for Joyce. Joyce's decline in appetite was reviewed. Joyce insisted that her appetite was fine. Logbook referenced with Debra to review total food intake for last 2 weeks was minimal. Debra also reviewed BGL, weight, medication, feedings, and incontinence (urine/bowel) frequency. Confirmed Joyce is not constipated. Appetite loss, increased or new dry cough, swelling in feet or legs, and tiredness or reduced energy puts Joyce in the "Yellow Zone" of the self-management plan for congestive heart failure (handout provided to Dusty) - swelling in feet or legs; increase in shortness of breath with activity or while lying flat; tiredness or less energy; change in appetite or less hungry; new or increased dry cough. Possible adjustment to Joyce's medications may need to be considered - Dusty to call Moscow Medical with health log data and see if carvedilol needs to be reduced and/or stopped. Debra also suggested to see if Joyce's metformin needs to be reduced and/or stopped as her BGLs are in a normal range now it may be unneeded at this point. Dusty confirmed he will contact Moscow Medical.

Debra reviewed Joyce's every day living (EDL) activities - dressing, laundry, meal preparation, medication administration, toileting, etc. - and that Joyce is highly reliant on family care to remain functional and safe. Joyce confirmed that she can dress herself (pull on clothing). 

Debra confirmed a Kindred nurse will continue to come out to check on Joyce at least once per week, future appointment time at farmhouse to be confirmed with Dusty. Debra uncertain who will be sent out next week due to rotating staff coverage and weather conditions that may prohibit access to the farmhouse due to vehicle capabilities if high snowfall occurs. Debra noting in Joyce's file that the nursing staff should keep an eye on the swelling in Joyce's legs, significant weight gain, or shortness of breath or breathing issues. 

Debra departed ~12:47 p.m. after giving Dusty "Self-Management Plan for Congestive Heart Failure" and "Self-Management Plan for Diabetes" handout.

Dusty negotiated a small lunch with Joyce after she refused initial options for her meal.

1 p.m. - Lunch (1/2 banana and 1/2 peanut butter sandwich with honey). 2 Tylenol for pain relief. Joyce refused to eat. As Dusty had to depart to return to campus he left the tray with Joyce who said she would work on it once she felt like eating.