RES HAB QUARTERLY PROGRESS SUMMARY MONTH

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RES HAB QUARTERLY PROGRESS SUMMARY
1ST QUARTER
MONTH: September, October, November 2018
Name:
FIDENCIO DAVID GARCIA
SSN: 589-45-9425
Address: 617 SW 83RD Terrace, Gainesville Fla. 32607
WAIVER SUPPORT COORDINATOR: DONNA WHILLBY
GOALS:
1) FIDENCIO would like to continue to work on improving his
overall basic living/selfcare skills in order to be as independent
as possible.
2) FIDENCIO would like to improve his personal hygiene.
3) FIDENCIO will continue to interact with the community
4) FIDENCIO would like to respond by gestures or sounds and
learn evacuation drills.
PROGRESS TOWARD GOALS/PERTINENT INFO:
1) Not much progress on improving selfcare skill he is total care
with ADL’s. No progress on being independent.
2) FIDENCIO’s personal hygiene improves with TLC staff doing it
on schedule and as needed.
3) FIDENCIO enjoy going out in the community, Theme parks he
enjoys long ride trip to Space Kennedy Center and Sea World,
loves to watch lights in different colors.
4) He can respond by gesture or sound, improved in participating
in the evacuating skills.
SIGNIFICANT EVENTS
FIDENCIO has been good in this quarter. He is stable and no
significant changes. Fracture in his left ankle
and left wrist are completely healed.
CONCERN AND ISSUES:
1)
2)
3)
4)
Has GT tube possibility of pulling out or getting clogged.
Risk of fall.
Risk of stoma infection.
Vulnerable for pressure sores and ulcers.
ASSISTIVE OR ADAPTIVE EQUIPMENT:
1) Customized wheelchair
2) Hospital bed with full side rails and air mattress
MOBILITY AMBULATION:
(any mobility that is not independent needs)
Walks independently without use of supportive devices
Walks with cane or walker independently
If not independently how much assistance
( ) Set up only
( ) One assist
( ) Supervision
( x) Limited Assistance
( ) Extensive Assist
( ) Total Dependence
Additional comment if not independent:
Unsteady gait.
TRANSFERRING:
( ) NO PHYSICAL help from staff
( ) Set up only
( ) constant 1 assist
( ) constant 2 assist
( ) Supervised
( x ) Limited assist
( ) Extensive assist
( ) Total Dependence
EATING:
( X ) N/A
( ) Independent
( ) Requires assist with eating (describe)
( ) Intake of 75% or more average for month
( ) Less than 75% (additional comments to accept/refusing
substitutes)
FEEDING:
( ) NASAL GASTRIC
( X ) GASTROSTOMY
( ) N/A
( ) OTHER
FORMULA TYPE: ISOSOURCE 1.5/JEVITY 1.5 EQUIVALENT
AMOUNT PER DAY: 5 CANS PER DAY
WATER AMOUNT PER DAY: 60ML Before and after feeding
If not tolerated detail:
BLADDER:
( ) CONTINENT
( ) Incontinent/Two hours toileting
( ) Foley/ Supra pubic catheter
( ) Yellow/Clear
( ) Amber/ Clear
( ) Other Describe:
Bowel:
(Any use of laxatives or softeners need additional description)
( X ) LAXATIVE
( ) SOFTENER
( ) OTHER:
ADDITIONAL COMMENTS:
Use LACTULOSE 20 ML 2X DAILY
PSYCHOACTIVE MEDICATION:
(Includes sedative/hypnotics, anxiety,
anti-psychotic)
( ) Not used
( x) Used
If used name of medication, positive or negative effects and side
effects.
QUETIAPINE 200MG 2X DAILY
CLONAZEPAM 0.5 MG ODT 2X DAILY
TRAZODONE 200MG AT BEDTIME
CHANGES IN MEDICATION:
( ) YES
( X) NO
Response to changes in medication:
Refer to MARS
RES HAB QUARTERLY SUMMARY:
FIDENCIO’S 1ST quarter is good. He rarely demonstrate healthcare
maintenance. He is on GT tube feeding ISOSOURCE 1.5 CAL (JEVITY 1.5
CAL equivalent) daily with free water flushing at 60ml before and after
each feeding. Tube feeding are tolerated well by FIDENCIO so with his
scheduled medication. His injury issue dated 8/20/18 involving Left
wrist and Left ankle foot, affected area of the left wrist was on a cast,
and the left ankle was stabilized by a walking boot which was
discontinued 10/17/18. Client also intentionally pulled out his GT tube
10/24/18 and was resolved on the same day new tube was replaced at
UF Health surgery clinic.
DOCTORS VISIT THIS MONTH:
10/1/18-----DR.RAFAMAN ( UF HEALTH ORTHOPAEDIC)
10/3/18-----DR. DORSEY (UF HEALTH FAMILY MEDICINE)
10/18/18---DR. BIANCHI (UF HEALTH ENDOCRINOLOGY)
11/6/18 ----UF HEALTH PSYCHIATRY OUTPATIENT CLINIC
12/5/18-----UF HEALTH FAMILY MEDICINE (DR. DORSEY PCP)
FUTURE APPOINTMENTS:
1/04/18-----UF HEALTH PEDIATRIC SURGERY (DR. TAYLOR)
1/22/18-----UF HEALTH NUTRITIONIST
2/20/18-----UF HEALTH EYE CARE CENTER (DR. BLAKE)
2/28/18-----UF HEALTH NEUROLOGY (DR. KALAMANGAN)
3/5/18------UF HEALTH FAMILY MEDICINE (DR. DORSEY)
5/7/18------UF HEALTH PSYCHIATRY (DR. BINDSHEDLER)
ADDITIONAL COMMENTS MAY INCLUDE FALLS, MINOR AND ACUTE
ILNESS:
FIDENCIO’S 1st quarter is good no falls noted; no significant changes.
Summary completed by:
Date: 11/30/2018
Aurora Martin BSN
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