5 mg, one tablet by mouth every Monday and Thursday; and the over-the-counter is a one-a-day women's multivitamin. DJ prefers taking her medications after breakfast.
DJ's general appearance was sturdy and well-kept. She was alert and oriented with no sign of acute distress noted. She appears clean and well-groomed; maintains eye contact with appropriate expressions; appears comfortable and cooperative; and her bilateral facial features appear symmetrical. Her skin appears thin, pale and wrinkled. Hearing is intact; wears reading glasses. Body parts equal bilaterally; stands erect; gait is uncoordinated due to bilateral lower extremities edema; walk is smooth but unbalanced, uses a cane.
Summary of Assessment Tool Results.
Overall, DJ did a wonderful job during the assessment. As much as DJ thinks she can do for self, I believe that she needs help with activities associated with daily living. Although she is capable of feeding, bathing, and taking her medications; she is unable to do any cleaning without becoming short of breath. She also needs help with meal preparations, housekeeping, and grocery shopping. She is cognitively intact except for recalling and calculation.
Health Promotion Patterns.
DJ weighs 105 pounds and stands five feet tall. She is a nonsmoker, and quit drinking alcohol and caffeinated beverages 40 years ago. DJ states that she eats whatever she wants, but in moderation. This habit is counter to her doctor's recommendation of a low salt diet, due to her medical condition. DJ sometimes has trouble preparing her meals when she developed bilateral lower extremities edema due to her heart condition. She states that when her feet are swollen, she has difficulty standing. She sometimes relies on her daughter (who lives two buildings over from her apartment) for meal preparation and grocery shopping. For physical exercise, she has an annual membership at the senior center one block from her apartment (Senior Suites of Chatham).
