Built from the full skilled-nursing portal export — labs, clinical notes, vitals, the echocardiogram, and the active medication list. It pulls the scattered numbers into one place so we can see the direction of travel and act on it together.
Where the worry was when she was ~2 weeks in (early–mid May, fresh off the hospital transfer) versus where the latest data puts her.
Two timescales. First the bigger picture — the years before this admission, so today's numbers read in context. Then the detail since admission, from her actual lab reports and vitals. Shaded bands show the normal range; points outside it are flagged.
One number tells the story of what changed. The heart-strain marker (a natriuretic peptide) was a normal ~36 back in 2023. It was 411 at this admission in April. On the newer, more sensitive assay the facility now uses it reads in the ~2,400–3,400 range and rising. Different assays don't sit on one line, but the direction is unmistakable: her heart went from compensated to strained, and that strain is the engine behind the weight (fluid), the breathlessness, and the oxygen need.
Same horizon (next ~13 weeks, to the care plan's mid-August review). The toggle compares staying exactly on today's regimen against making the corrections on the next tab. Both lines land us at the same date — the question is which numbers we arrive with.
Concrete, evidence-informed things to raise — in priority order — with the facility, the PCP, cardiology (June 11), and a future psychiatrist. Each is framed as a question/ask for her clinicians, with the reasoning so the family can advocate from the same page. None of this is a self-directed change.
Diet is not a side issue for her — it sits at the center of the diabetes, the heart failure, and the weight, all at once. The good news, from her own history: we already know what works. The problem right now: at the facility she chooses her own meals, and the choices are working against her. This tab lays out both.
The facility lets residents pick their own food. That's her right — but with her conditions, several routine picks are genuinely risky, and no one is steering them.
Her record holds one of the most effective interventions in her whole history, and it was about food.
The low-carb framework still applies — but three constraints have been added since 2025, and the dietitian/cardiology/nephrology need to set the exact numbers.
Both targets are already in her facility care plan. The point isn't speed — it's steady, real (non-fluid) loss that her heart and kidneys can tolerate.
A cheat-sheet the family can hand the kitchen or post in her room.
| Instead of | Choose |
|---|---|
| Orange juice, soda, sweet tea | Water, sparkling water, unsweetened tea/coffee (OJ only for a low) |
| Sugary cereal, pancakes, toast | Eggs, plain Greek yogurt, cheese |
| White bread, potatoes, white rice | Non-starchy vegetables, side salad |
| Cookies, cake, ice cream | A small portion of berries, or a sugar-free option |
| Canned soup, processed/cured meat, gravy | Fresh-cooked, no-added-salt, seasoned with herbs/spices |
The medical team manages the medicine. This is the part that's ours — the things family does that genuinely change how the patient does. It's drawn from what she's actually told her care team: she misses home and her cat, she's frightened of falling again, she lights up about going home but gets tearful about it, and she mentioned food has sometimes been tight. Below: what to do, what to ask, and a running list you can fill in and bring to every appointment.
Her depression screen went from mild to moderate while she's been here. This is the part of her care that isn't about medicine — and it can do what no medication can.
She tends to agree with providers under time pressure, and her cognitive screen showed mild impairment — so what gets decided in a 10-minute visit may not be what she'd choose with time to think.
She's going back to a ground-floor apartment, on oxygen, walking short distances with a walker. The fall is what started all of this — home has to be ready before she is.
For her conditions, these are the things that warrant a call to the office or, where noted, 911. Put them on the fridge.
Care like this is a lot for anyone to carry. It tends to go more smoothly when it's shared — and there's no single right way to do that. Roughly, the work falls into two kinds; how (and whether) to split it is entirely the family's call.
However the family chooses to share this — or not — the only goal is that nothing important falls through the gap. What each person is able to give will vary, and that's completely okay.
Jot anything you want to raise or that's worrying you — a symptom you noticed, a question for June 11, something that doesn't sit right. It saves on this device and travels with you to the next appointment. Check items off once they're answered.
A visual day, slot by slot, built from her current active medication list. Check off doses as they're given, drag a card (or use Move ▾) to shift it to a different time, and your layout + check-offs save on this device per day. Use the Reset day button each morning.