Care Plan Activity Report

Kings Harbor Multicare Center

Resident: Barksdale, Clydia
DOB: 6/15/1928 (96 y)
Unit-Room-Bed: M1 - 114 - A
System/Facility ID: 19302 / 041353

Selection: Scheduled Date: 3/11/2025; With Corrections: From 3/5/2025

Notes	Status / Date
Nutrition Assessment: 94 y/o F with Active dx/PMHx: Chronic atrial fibrillation, HCVD with chronic diastolic CHF, Generalized OA, Dementia, DM2, Tricuspid regurgitation, Pulmonary HTN as per MD 8/31/22.
Current weight is 132,4# (9/6/22), BMI 26.7: Category: Overweight. Diet is: PROVIDE SUGAR SUBSTITUTES AND DIET CONDIMENTS TO AID IN DM MANAGEMENT, Regular Level 7 (Regular) consistency.
Labs: 8/10/22: Glu 102 H, A1C 6.7 H, and adequate for age. Rx of Metformin noted to manage DM, therapeutic liberalize diet appropriate. Juice at lunch d/c, NGS will provide water instead prn. Fluid intake adequate with 75 % - 100 % as per ECNAAR to maintain hydration. No visible s/s of fluid deficit noted.
No edema, Skin; No PU/PI, and not GI disturbances reported, and malnutrition as per MD 8/31/22 r/t comorbidities, advance age. Medications receive by resident with potential negative effect on appetite and weight are (metformin, Cardiac, Metformin, Antithrombotic, Diuretics, Tylenol). Monitoring and POC continue.	Created On: 9/06/2022 Entered On: 9/06/2022 Entered By: Tetteh, Augustina
Nutrition Assessment Competed for 94 y/o female with Active Dx: Chronic atrial fibrillation, HCVD with chronic diastolic CHF, Generalized OA, Dementia, DM2, Tricuspid regurgitation, Pulmonary HTN, Mild Malnutrition as per MD 12/8/22.
Resident continue to present gradual/beneficial weight gain this period. KH Labs: 12/13/22: Glu 128 H. DM meds; rx Metformin noted. PO intake is encouraged by NSG on the unit to aid with hydration and skin turgor; fluid intake also varies as well, however overall intake if adequate 100 %, 75 %, and some 50 % as per ECNAAR. No visible s/s of fluid deficit noted. Skin is intact, and no edema. Resident with Mild Malnutrition as per MD 12/8/22. Medications with potential negative effect on appetite and weight are (Tylenol, metformin, Cardiac, Metformin, Antithrombotic, Diuretics). Monitoring and POC continue.	Created On: 12/19/2022 Entered On: 12/19/2022 Entered By: Tetteh, Augustina
94 y/o female with NKFA, with Dx:/PMHx: Chronic atrial fibrillation, HCVD with chronic diastolic CHF, Generalized OA, Dementia, DM2, Tricuspid regurgitation, Pulmonary HTN, Mild Malnutrition, Hyperkalemia, as per MEDs 3/10/23, and 2/22/23.
Resident noted with stable wt in 1 month, and slightly with gain of +3.9#/± 2.7 % in 3 months, and weight gain of +11.7#/± 7.7 % in 6 months (weight changes is not significant). KH labs 3/13/23: K+ 5.2 H. MD aware. No hydration labs to report at this time. Noted with mostly 100 % and 75 % or less acceptance of PO fluid as per ECNAAR, and encouragements ongoing to optimize hydration. PO intake is encouraged by NSG on the unit to aid with hydration and skin turgor; fluid intake also varies as well, As per MEDs 2/22/23 resident with no edema, Skin: No PU/PI, and no gi disturbances. Estimated nutritional/fluid needs met with current dietary regimen to deter risk. Will continue to monitor and intervene prn. POC continue.	Created On: 3/17/2023 Entered On: 3/17/2023 Entered By: Tetteh, Augustina
Resident is a: 95 y/o female with NKFA. PMHx: A-fib HCVD with chronic diastolic CHF-off Lasix, OA, dementia, DM2, Pulmonary HTN, Mild dysphagia-per speech 6/15/23. Appetite is good-eating varies between 50 - 75 % of meals with set up/supervision. Resident eats most food groups on a liberalized diet Soft & Bite Sized Level 6 (Mechanical soft). Is PROVIDED SUGAR SUBSTITUTES/DIET CONDIMENTS. Resident will continue to benefit from HiCal/HiPro foods: 6 oz hi-cal/pro cereal @ B (253 cals, 7 g pro); 2 oz hi-cal/pro eggs @ B (287 cal, 17 g pro) to optimize nutritional needs and stabilize weight; encourage fluids to optimize hydration. Current weight is 144.6# (3/1/23), BMI 29.4; Overweight. Goal is weight stability x 30 days. Skin intact. Resident on polypharmacy-potential effect on weight and appetite such as (Cardiac, Metformin, Antithrombotic, Tylenol). Estimated nutritional needs met with current dietary regimen to deter risk. Will continue to monitor and intervene prn. POC continue.	Created On: 6/19/2023 Entered On: 6/19/2023 Entered By: Ronco, Lisa

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