Social Support Assessment.
The patient lives with her spouse and has assistance available around the clock. The patient receives assistance from her spouse for ADLs and IADLs. The patient has a call button, emergency response button, or smart device that enables the patient to get assistance when needed. The patient is receiving support services from community or religious organizations for food, shelter, finances, emotional support, or other needs. Description of support: The patient will receive meals from her church for the next two weeks. The patient has no additional need for support at this time.
Home Safety Assessment
The patient lives in a multi-story home with 3 steps to enter. The patient must navigate 1 flight of stairs to reach the bedroom. The home has dirt, clutter, and narrow walkways which are concerning for patient safety. Patient is able to leave the home with the assistance of an available caregiver or family member in case of an emergency. The home has no other significant concerns relating to home safety/maintenance that would impact patient safety. Patient will have a spouse clean and remove clutter to improve safety.
Catheter Care Goal
The patient will demonstrate a comprehensive understanding of proper [type of catheter, e.g., Foley, suprapubic] care, and the [type of catheter] will be changed at the prescribed intervals, every [frequency of catheter change, e.g., 4 weeks], as per physician's orders, to ensure optimal function and prevent complications. 8 weeks.
General Appearance Assessment:
The patient is seated comfortably in a recliner and is wearing clean clothing. There's noticeable weight loss since the last visit. Her skin appears dry, and there are dark circles under her eyes, suggesting potential issues like dehydration or poor sleep quality.
Pain Management/Evaluation:
Evaluated the patient's reported lower back pain. The pain was rated as 2 out of 10, described as a mild, dull ache. It slightly increases with prolonged sitting but doesn’t hinder daily activities. Advised the patient on the importance of regular gentle exercises and frequent posture/position changes to alleviate discomfort. Reviewed the use of over-the-counter analgesics, emphasizing the recommended dosage and frequency. Discussed the implementation of heat therapy as a non-pharmacological pain management technique.
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