History
82 year old female with admitting diagnosis of (LT) Hemiparesis, S/P (R) endarterectomy. On admission to Blaire House patient could ambulate with roller walker and minimum assist. Transfer from sit to stand was contact guard. Balance was impaired. Patient needed minimum assist to get out of bed and had not attempted stairs.
Past Medical History
Carotid stenosis, Type II DM, HTN, hyperlipidemia, hypothyroidism, old infarct
PLOF
Patient lives with daughter who works an 8 hour day. Patient has an apartment in the basement (1 flight of stairs). Plan is to discharge home with daughter.
Primary medical diagnosis: S/P (R) endarterectomy
Payor source: Blue Cross/Blue Shield
Plan of Treatment:
Physical Therapy 5 days/wk
Occupational Therapy 6 days/wk
PLAN OF CARE WITH MODALITIES
OT POC
- Independent self care at chair level
- Supervised at shower level
- Independent hot meal prep
- Demonstrate good endurance and (L) upper extremity strength
Resident very motivated and demonstrates good carry over for new learning.
Resident successfully achieved goals. Adaptive equipment for bathroom was recommended as well as home occupational therapy for safe discharge plan.
PT POC
- Ambulate with appropriate assistive device independently
- Up & down flight of stairs using one hand rail
- Dynamic balance FT with assistive device
- Increase (L) lower extremity strength
CLINICAL BENEFITS/OUTCOMES
At time of discharge patient could ambulate with a rolling walker independently. Needed close supervision for use of quad cane, needed close supervision for going up & down stairs with quad cane and one hand rail. Caregiver training was completed before discharge. Patient was recommended to stay on first level for the first couple of weeks after discharge. Physical therapy at home will clear for independent stair/cane use. Resident successfully achieved occupational therapy goals. Adaptive equipment for bathroom recommended as well as home occupational therapy for safe discharge plan.
Quality of Life
- Decreased pain-increased ability to sleep, eat, participate in life activities
- Increased independence in ADL as resident regains increased function
- Decreased dependence on adaptive equipment
- Increased ability to return home and resumption of previous life activities