Caregiver/CNA

Social History:  Client served as a Lieutenant in the Navy for a number of years.  

Diagnoses:  T-7 fracture of spine, Erratic Blood Pressure, Bilateral Hearing Loss w/aids, Chronic Cough due to allergies.  Allergies:  None to food but Meds- Carvedilol

Goals & Objectives:  Medication reminder at shift start. Plan, prepare & cook healthy, well-balanced dinner meal each shift, keep running grocery list. Clean kitchen afterwards. Hydration reminders. Accompany to Dr visits or errands as needed on specific days. Standby assist with shower each shift, helping gather clothes. May need to assist with dressing if asked.  Laundry/bed linens weekly as needed. Light housekeeping if needed-gathering garbage).  Bring in mail if needed.

ADL's:  Mobility:  Client  can get himself up from a seated position onto his walker.  He walks slowly with a new Ninja rollator. If her gets tired or if he feels his BP drop, he sits down.  CG should observe and/or walk with him regarding balance. For longer distances, he should use a transport chair.  Cliff needs CG to accompany him to Dr appts and may need to drive for him. He will need help into and out of his car.

Eating:  Eating better is his primary goal. Client  can feed himself.  He needs a healthy, balanced, evening meal planned, prepared and served to him each shift.  He enjoys a meat n 3 type meal. He has no food allergies and is not picky.  He reports to have no swallowing difficulties. 

Bathing/Dressing/Grooming:  Client  can shower independently but would like CG to standby if needed. He said he is very careful and has a shower chair, support bars and a handheld showerhead. He can brush his own teeth. He chooses his own clothes and dresses himself but may ask for help with fasteners. 

Toileting:  Toilets independently. May appreciate standby assist so CG should ask when he needs to go. He wears depends in case of any accident. He does know when he needs to go.

Communication:  Client speaks clearly and enunciates fairly well but talks at a low volume. He does wear hearing aids in both ears but seems to need CG to speak a little loud and clear. He is highly computer-literate and an excellent communicator per email and text and does this often.