Mom medical

discharge planning

• Nadia, Nurse Discharge Planner talked to Jean about Private Hire around the clock care until she is strong enough to be alone. She was given a list as they cannot recommend one over another. We received this card: Privatus, Client Services Manager Carolyn Dubicki Eipel, 516 491-5196.
• Catholic Homecare is connected with St Francis. Medicare B will pay for Nurses and Home Health Aids from, United Health Insurance will pick up copays.
• WALKERS: will be paid for by Medicare B, one every 5years. Jean will receive the script when she leaves. Medicare only offers two walker models and the PT will help pick the best one.

CVS 930 MONTAUK HWY COPIAGUE (631) 842-5381 GENOVESE DRUG STORES INC 901 MERRICK RD This means the supplier always accepts assignment for the category, which means they accept the Medicare-approved amount as payment in full for all claims for the category.

questions

3/7/20

• megan PT will help mom pick out walker and then it will be there when it arrives?

3/3/20

• What was learned from the CT scan?, ANS: they decided to let her throat heal on its own

notes

• 3/9/20
• 3/7/20 Saturday

Coleen: I got here at 9a.m. and see that all the action happens early morning. Mom was being bathed and soon after, moved to the chair. Dr. Zisman, was in and confirmed that the esophagus test Monday will give them an idea of how and if the tear is healing and whether or not they could begin to feed her. Mom said 'that means I can get out Friday' and the doctor said that if she is able to eat as of Monday, she could be released even sooner. Mom is acknowledging the fact that she will need live-in professional help for a while when she returns home. I am going to push for PT walking today. Mom's coloring is good.

• Giving mom potassium as it was a little low. NG tube going back to suction. Celifarco flushed the tube last night so it is working for Med intake

3/6/20 Friday

• when we left we had yet to see Dr cilefargo. The nurses don't use the NG nose tube 4 meds and it is kinked so it is not even working to do decompression. He has the power to take the damn thing out. Check with Stephanie the nurse, if none of us are there she will have talked to him.
• 1pm Endocrinologist in, blood sugar 155, lowest yet, Hemoglobin A1c was 4.7 (excellent), receiving NPH insulin 14 units twice a day, most likely will not need insulin once off the steroid and the TPN feeding (glucose in TPN reduced yesterday) .
• 12 noon Dr Lopez Infectious Disease Doctor was in, antibiotics continue, Chief of Pulmonology was in and taught Jean to use the inspiration exerciser which she was not able to use correctly, long sustained breath with an adequate seal made by lips but he was not concerned as he determined that it was not an adequate measure of her breathing status, chaplain was in and said that she will be away next week but to call for Pastoral Care ext 6720 or 6459 (Lead)
• Discharge Planner was in,
• 11:30am walked around
• Dr Chung also said he would be fine if Dr Celifarco decided to remove the NG (nose) tube since she was only getting one med through it anyway and mom's blood pressure was 127/71.
• Dr Chung came in, agreed the swelling in mom's feet was better with the compression socks so he stopped the Lasix (hooray, made mom incontinent and only given because she asked for it, also caused the staff to stop letting her walk)
• xray showed NG tube kinked, can’t be used for one blood pressure meds and the cholesterol med, others are by injection or IV.
• feet no longer swollen, no shortness of breath,

Dr Chung ordered 3 days of lasix to address Jean’s concern over her feet (and misconception that her wt had gone up to “160” sounds like 116) but this has caused her to have decreased mobility as she can’t control the increased flow of urine (lasix doing what it does)

3/5/20 Thurs 12:20 xray done

• 12 noon Latoya NP in, Dr Celifarco ordered X-ray to check on nasogastric tube placement.
• 10:30Dr Chung in, spoke to Dr Celifarco, cancelled the radiology consult for the feeding tube, prefers, after barium swallow on Monday to assure healing and no leak, to start taking food by mouth.

Wayne, PT walked, no shortness of breath.

• Dr Lopez, Infectious Disease, continue antibiotic to prevent infection until healing confirmed.
• 8:30am Dr Celifarco in, said that radiologist will be in today to discuss insertion of feeding tube near navel which would allow the nasal tube to come out.

Also that next Monday a repeat barium swallow to assess the healing in the esophageal neck area. Nurse Caitlin explained the feeding tube. (see notes)

• 6:30 Dr Zisman, Primary Care provider (associate of Taybac) was in evaluate Jean

3/4/20 Wed

• 6pm Dr Celifarco was in to check the NG tube that the nurses are finding finicky. He pulled back the tube put saline through a now smaller more comfortable tube (I don’t know when he changed it) that requires the nurses to use a little more force.
• 3:20 1st walk today
• Melissa again tried to Clear the feeding tube, after the tech came in to adjust it but it didn't work. She says the same thing happened last night they did a scan that also was worthless, without some kind of dye it is too small to see. So no, it is not working for meds and is too small to ever be used for food
• got a coverage insulin of 4 at 1:30
• 12:45 blood sugar 311
• another CATscan, to find where the NG tube is, happened
• nutritionist explained that one reason to look forward to moving from the PICC to feeding tube is that the gut will atrophy if food is coming only from the blood
• Dr Chung downplayed the ng tube problems, says you can just jiggle it to another place so it works but defers to Dr Celifarco on what should happen with it. Suggested that things were stable and that mom might be ready for a regular hospital room. He has been in touch with Dr Serpe. Mom and Dr Chung had a conversation comparing how she felt after walking to the mailbox before the surgery to how she felt walking around the hospital yesterday. Mom said she still felt weak but that now walking now she doesn't have that feeling of racing beating heart as much.
• 8am looking good, Dr Celifarco was in and will get back to the nurses about changes in the nasogastric tube that will allow her to get feedings through it, a better level of nutrition than the TPN she gets through the PICC line.
• Melissa day nurse

3/3/20 tues

• 9:45 sharp pain in left lower belly, pain when pressed.. May be gas. Was to receive mylanta through NG tube and found that there was resistance, Latoya Nurse Practitioner moved the tube but still wasn’t patent, ordered bedside X-ray to check on placement.
• Received Lovenox injection and they hung new TPN bag.
• In the morning have the nurse page to request a chaplain visit or call ext:6459 there is a card on the window sill.Chaplain came, we prayed. Mom asked for a miraculous medal and maybe a rosary.
• We called Karen to take in the papers and packages
• 1:30 pm sugar is 323, bp 136/94 temp99, got 'coverage'4', notified endocrinologist
• physical therapist took her for a walk around the floor. Said she needs to walk and do her exercises every day. She is out of breath. Then she lifted her leg bending at the knee 20x and lifting her knee up 15x. You cannot go home if you cannot walk.
• Dr Lopez stopped in.
• the NG nose tube is also used as a way to get mom meds. After giving meds the close off the tube for a while so the meds stay down.
• mom is getting lovrinox injections as a Cumadin replacement
• Mary the respiratory therapist stopped by with a session of nebulizer. Mom got a new mask with cool moist air to lower her problems with mucus.
• Mom is tired probably partly from the steroid she is taking and the (somehow connected) rise in her blood sugar level. Dr Chung spoke of bringing in an endocrinologist to consult.
• Dr tavak still a no show. Nurse is calling again
• Dr Kaushik was here with Dr Chung (who is still quarterbacking) The consensus on the throat is to leave it to heal on its own for 2 weeks. Feeding will be from PICC and they might experiment having the nose tube be used for some of her meds like Cumadin and blood pressure meds. It does not seem to be worth it in their view to put in a stomach feeding tube for the two weeks. She will likely have to remain in the hospital for two more weeks.
• Celifarco is consulting w another GI doc kaushik whose np Palmieri says they think endoscopic clip install is the way to go.

3/2/20 mon

• At 7:30pm ENT Dr Wodlin came to say that the injection to treat the “paralysis” is not needed now but may be before she starts ingesting food.An Esophogeal surgeon came in and weighed in saying “less is more” he would not opt for the drain or the incision to clip the tear The clip could close in fluid that could then lead to infection. An image of the area may look very different in a week.

• TPN nourishment through the PICC line new bag started at 9:30pm Jean was restless and pulled off the mittens.
• At 6:30pm Jean had a CT scan of her throat and chest to get more information (ie how deep is the tear)
• In the afternoon Dr Celifarco on the other hand, sees a collection junk in the esophagus wound and is recommending a drain. He's got a guy coming to look that and also evaluate whether they could non-surgically reach in and sew up the tear. He thinks drain first, feeding tube second. He agreed that a feeding tube entering the belly,done by a radiologist, so that it wouldn’t have to go through her esophagus would better allow the throat to heal.
• After the barium X-ray Dr dimeo came and said the tear was pretty high up near the vocal chords. Out of his territory. Recommending and consulting w general surgeon. Thinks surgery to put in neck drain is unnecessary now, use antibiotics instead.
• Dr Lopez the Infectious Disease specialist started antibiotics for esophagus wound, to prevent infection as there is no sign of infection (elevated white cells)
• So the trauma sustained that is keeping her from eating is both a partial paralysis and a tear of her esophagus. She has a PICC line (not in her chest but in her upper arm) and an NG tube. The NG tube is being used for medications. She is having a barium type swallow esophogiagram now with some water based substance to determine where the tear is located. result: long tear left external, high up but not sure how deep. The radiologist suggested that it might need to be repaired surgically, hope not.

• working on getting a primary care physician on board to coordinate and have the big picture

3/1/20 sun

• The ENT doc was just here, he says that her vocal cord is still paralyzed but that he has to wait to hear from her doc about where the tear is located. If it is along the shared wall with the wind pipe it is harder to take care of the shot (which usually is an instant cure for vocal paralysis, but if it is on the exterior wall of esophagus, much less complicated. He will consult with the doc looking at her esophagus after he knows the deal and work with him.
• The nurse Min said that all of the nutrients are being provided through an I.V. The 'feeding tube' is exclusively for medication.
• GI guy was here this morning and left note saying that an ENT person will come tomorrow to take a look at the current state of mom's esophagus tear.

2/29/20 Sat

• Feeding tube can't be used for 24 -36 hrs. Today a PIC line will be put in so she can get iv nourishment with protein carbs and fat. However her INR number is high so there is a hold on that.
• mom still not getting food
• The injection for the vocal cord was not done, the feeding tube was placed last night. The tube is a nasogastric (NG) tube and as of 10am there was no order to start feedings

2/28/20 Fri

• ENT doctor/- Dr Saul Wodlin examined mom's throat with a small scope and told me that the left side of her vocal cord is paralyzed. Stated this is the reason she cannot swallow or talk. The solution is to give mom an injection and this will very quickly repair the problem. The main issue is timing. This was just diagnosed , the OR is booked up. He is pushing very hard with everyone at the hospital to do this ASAP. If this can be done and if successful ( the doc is very confident) the feeding tube will be unnecessary.

2/26/20 Wed

• the main issue remains the throat trauma. Not able to ingest any liquids or food. The steroid that started 2/25@ 11:00am has been given regularly and the hope is that this can greatly aid in the throat healing. By later this afternoon doctor will evaluate the potential insertion of a feeding tube. They hope to avoid this for the potential strain on the throat could outweigh the nutritional advantage.

2/25/20 Tues

• Much less pain and discomfort today. Last night her doctor said one lung was not functioning - he used an endoscope to diagnose the problem. Detected a large amount of mucus around the lung and was able to suction it out. Started a new medication to help with breathing.
• Dr. Chung checked in, and is concerned about mom's throat, and the fact that she has not been able to drink or eat anything. Says she will remain in the ICU until her problem is resolved.

people

• MICU Patient Care Attendants Anica, Ryan, Megan,
• MICU Nurses Melissa, Michelle, Steph, Caitlin, Stephanie
• MICU NP Latoya
• Dr. Chung - heart surgeon - installed the mitral valve clip
• Novlet Cardiology NP
• Dr Saul Wodlin - ENT doctor - 2/28 the reason she cannot swallow or talk:the left side of her vocal cord is paralyzed
• Danielle - ENT nurse -
• Dr Celifarco - GI doctor, 2nd in command to Dr Chung
• Dr Tavak - primary care
• Dr Zisman, primary care, associate of Tavac, Zisman examined Jean on 3/5 and checke din on her 3/6
• Dr Lopez - infectious disease doc
• Dr Dimeo - cardiac thoracic surgeon
• Dr Kaushik director of Gastroenterology, 515-590-3700 https://ligastroendo.com
• Roberta Palmieri is NP of Kaushik

Nadia Stokum, Nurse Case Manager for Discharge Planning