General Update #247 - Wednesday, December 16, 2020 (Updated)

NOTE TO FAMILY CARE PROVIDERS: Starting today, 12/16/2020, Metformin medication no longer being administered to Joyce per Dr. Collins. Dusty has removed it from the dosage cups he prepares.

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Dusty arrived ~8:30 a.m. to farmhouse, finding Joyce awake. Joyce was visiting with Craig and watching White Christmas.

Dusty shoveled snow off back patio and Craig brought Joyce's Subaru around back in preparation for today's travel into Moscow for appointment with Dr. Collins.

Found note left yesterday from Connie, Joyce was given a new stress relief blow-up pillow which was recommended to relieve pressure sores and help Joyce sit more comfortably. Blow-up pillow has been deployed to Joyce's recliner under waterproof protector sheet.

8:38 a.m. - Bathroom trip, urinary incontinence. Diaper pad insert replaced. Wound cleaned and fresh barrier cream applied. Possible new pressure sore developing on left buttock. PT walk to living room and returned to recliner by 9 a.m. and prepped for appointment with Dr. Collins (dressed in fresh clothes, deodorant applied, face cleaned with washcloth, wool socks put on). 

Dusty confirmed with Craig that he can cover morning care for Joyce on December 29 and January 6 as Jess and Dusty have their own medical appointments those mornings. Joyce's hallway care calendar updated to reflect Craig's coverage of those dates.

9:04 a.m. - BP 163/86, pulse 85. BGL @ 121. 

9:06 a.m. - Breakfast (2 Eggo waffles with peanut butter and apricot jam). Morning medication given to Joyce with nutritional shake. Breakfast finished by 9:30 a.m.

9:30 a.m. - Bathroom trip declined.

9:45 a.m. - Bathroom trip declined. Joyce made ready to be loaded into Subaru for travel to Moscow.

9:50 a.m. - Bathroom trip without incident, urine passed.

10:10 a.m. - Checked in at Moscow Medical for 10:15 a.m. appointment. Admitted to examination room and discussed items of interest with Wendy, Dr. Collin's nurse (left knee/leg pain and intermittent loss of functionality or "locking up;" allergy medicine approval for treating Joyce's dust allergy - Mucinex dose in mornings and 24-hour Claritin dose in evenings; potential switch off of Metformin in attempt to alleviate Joyce's loose stool and bowel incontinence issues; gain permission to add Lactaid supplement for Joyce's medications to aid with loose stool and bowel incontinence issues; potential administration of anti-diarrhea medication to Joyce to aid with loose stool and bowel incontinence issues; flu shot; memory issues and reason for discontinuation of prior medication that was being administered for assisting with that; new wheel chair order with NW Respiratory from October; mouth sores Joyce recently developed).

Joyce's vitals were taken by Wendy. BP 134/72 ("really good), pulse 84, temperature 98 degrees Fahrenheit, oxygen levels at 96%. 

Joyce reported that she had no fever and was not experiencing nausea when asked. Joyce reported no nose or ear pain, no loss of sense of smell, taste, or other COVID-19 symptoms. Lymph nodes were inspected and appeared fine. Joyce's breathing was checked by Dr. Collins and determined to be fine. Joyce self-reported that she had difficulty breathing deeply for Dr. Collins as she was checked with the stethoscope. Dr. Collins thinks that Joyce is most likely having chest congestion from dust allergy and shallow breathing on a regular basis (most likely due to how she sleeps/rests hunched forward in her chair which prevents full expansion of her lungs on inhalations). Recommendation that family care givers work with Joyce on breathing exercises on a daily basis if possible. Joyce's heart was checked by Dr. Collins and deemed "sounding good." 

Sores in Joyce's mouth inspected by Dr. Collins after she reviewed information collected by Wendy and Dusty. No signs of infection in gums. Dr. Collins determined that the sores are possibly either cold sores, canker sores, or (most likely) a result of Joyce breathing through her mouth more due to her nose running constantly over the last few days. Dr. Collins does not think gum irritation is from Joyce's lower front teeth fragments rubbing/cutting into her gum tissue as Dusty hypothesized (from chewing or teeth grinding movements) - Joyce's upper lip appears to be most likely causing friction damage to the gum tissue. Dr. Collins prescribing an oral analgesic gel to provide relief to Joyce which pharmacist will fulfill. 

Dr. Collins confirmed that Kindred nurse was correct that administering Claritin and Mucinex to help alleviate Joyce's dusty allergies are acceptable to continue. Dr. Collins recommends switching Joyce off of Claritin (loratadine) and onto Zyrtec (cetirizine hydrochloride) instead as it will most likely be more effective for her. 

Pressure sores confirmed to be healing, family care givers commended for cleaning and protecting them with barrier cream. Confirmed that family care givers have provided Joyce with seating adjustments and are getting Joyce up to walk around the house several times per day.

Confirmed compression stockings being utilized along with leg elevation to reduce swelling in lower extremities.

PT and OT exercises should be continued per plan left with family care providers as Joyce is able. Dusty confirmed that they are not always able to be conducted due to Joyce's mental attitude or fatigue issues.

After reviewing health log of bowel movements, meals, and blood glucose levels Dr. Collins directed family to stop administering Metformin to Joyce all together effective today as Joyce's BGLs have been fairly good since October. Family should continue to track Joyce's blood glucose levels to provide to Dr. Collins at Joyce's next appointment in 1-2 months. At that appointment, Dr. Collins will review the data and determine if a Metformin alternative is needed at that time or if Joyce can continue without it. Dr. Collins is hoping that removing Metformin from Joyce's system will help alleviate the bowel incontinence and loose stool. 

Anti-diarrhea medications and fiber supplements NOT recommended for Joyce. Dr. Collins expressed concern over causing Joyce constipation if these are used, preferring Joyce continues with regularly occurring bowel movements. Plan is to start with discontinuation of Metformin for 1-2 months and see if positive effects result. Alternate options to be reviewed at next appointment if loose stool and bowel incontinence issues persist.

Dr. Collins inspected Joyce's left knee, finding it to have "severe arthritis." Dr. Collins will submit a prescription for nabumetone for pain relief to Joyce's pharmacist for fulfillment. This should help Joyce with her pain and "lock up" issues she has been experiencing.  

Dr. Collins reviewed Joyce's prescriptions from pre-June 2020, determining that there was no reason the  dementia medication, Arisept (donepezil), should have been stopped medically. Dr. Collins had no notes about side effects such as dry mouth or dizziness in Joyce. Dr. Collins suspecting that it was stopped to help reduce amount of medication Joyce was receiving while at Gritman in June and was simply never re-started while she was in Aspen Park's care or in September when Joyce returned home to farmhouse. Dr. Collins re-added donepezil to Joyce's medication list and will submit an order for its fulfillment to Joyce's pharmacist. 

Wendy and Dr. Collins will revisit wheel chair order through NW Respiratory that fell into limbo in October.

Wendy and Dr. Collins praised the health log the family caregivers have been keeping as it gives them a much better idea about Joyce overall. Recommendation is for it to continue with importance of tracking Joyce's blood glucose levels, weight, blood pressure, and bowel/urine output. 

The plan is for Joyce to have her blood drawn at Moscow Medical at her next appointment in 1-2 months.

Next appointment with Dr. Collins scheduled for February 16, 2021 at 9:20 a.m. - Dusty will request time off from work to take Joyce to this appointment.

11:15 a.m. - Bathroom trip without incident. Joyce passed urine and bowel movement (type 5) at Moscow Medical after meeting with Dr. Collins concluded. 

11:30 a.m. - Flu shot for Joyce administered at Rite Aid pharmacy.

12:15 p.m. - Returned to farmhouse. Bathroom trip without incident. Urine passed.

12:30 p.m. - Lunch (McDonald's cheeseburger and fries, small can diet Pepsi) - All food eaten. 2 Tylenol. Joyce began napping after lunch finished ~1 p.m.

2 p.m. - Bathroom trip declined. Joyce returned to napping.

2:15 p.m. - Bathroom trip declined. Joyce returned to napping.

2:30 p.m. - Bathroom trip declined, Joyce resumed napping. Dusty departing farmhouse ~2:45 p.m. to return to working at his office on campus.

Carol arriving to provide evening care for Joyce.

6:30 p.m. - Dinner (sloppy joe sandwich, green beans). Evening medication.

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Dusty planning to pickup prescriptions from pharmacy once notified they have been filled.

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