Assessment Plan Assignment
Below you will see a summary of two different 1 hour treatment sessions for the same patient as well as a section summarizing the patient’s information.Please write the Assessment portion of a SOAP note based on how the patient performs from treatment session 1 to treatment session 2.Please also write the Plan section of the SOAP note including at least 2 ideas for treatment. The ideas need to be appropriate for the level of this patient.
Patient Information:Dx:CVAc L hemi.Weakness noted t/o L UE and L LE.Pt does have active movement in her L arm, but having difficulty grasping and manipulating objects.Pt c 3- strength in her L quads and 2 in her L gluts.Her static supported standing balance is F/F+, however, her dynamic supported standing balance is P.She is using a LBQC for amb.
PMH: HTN, CAD, NIDDM, S/P THR in 2009
Home Information:One story home with 3 STE with no HRs
Social Information:Pt likes to play golf.
Treatment Session One:January 31, 2010 at 1:32 p.m.
Pt arrived to Rx session in a w/c.She was not feeling very well.She said she was feeling very tired; hadn’t slept well the night a.Pt noted to be very quiet t/o Rx session, and appeared sad.The Rx session began with PTA t/f pt → mat with pt using her LBQC.PTA had to give mod. PA.PTA noticed that pt puts all of her weight through her R LE and pushes post. during sit stand.Once pt is on mat, PTA works c pt doing repeated sit stands focusing on proper technique.PTA then has pt step ↑ on 4” step c R LE and reach ↓ and ↑ for bean bags c L UE, and toss into container.Pt needed to rest after about 10 bean bags for each of attempts totaling 4 attempts because of fatigue and SOB.O2 sat was 89% after 1st attempt and noted to be 92% within 1 minute of sitting.PTA completed gt. training having pt use her LBQC.PTA had to give mod. – max. PA.Pt amb 25’, was unable to advance her L LE I, consistently looked down and hyperextension of her L knee was noted 75% of the time.1 significant LOB noted when pt’s family arrived and pt turned her head to the L.After gt. training, PTA took pt back to her room.
Second Treatment Session:February 1, 2010 at 2:40 p.m.Pt arrived to Rx session in a w/c feeling better this date.Stated she slept much better last pm.The Rx session began c PTA t/f pt → mat using LBQC.PTA had to give mod PA.PTA noted pt to have some post. pushing and pt putting more weight thru L LE during
sit →stand.PTA continued to have pt. practice sit stands at varying heights.PTA also had pt put R LE on 4” step and throw ball against a wall at various targets.Pt noted to be SOB with activity, taking frequent rest breaks.O2 sat 93%.PTA ended Rx c gt. training using LBQC.Pt having difficulty remembering what foot to move first.Pt looking down less with VC and TC from PTA.Pt starting to advance L LE on her own, however, PTA still needing to clear her L foot.Pt amb 30’ c mod PA – max PA from PTA, and pt able to control knee better.Pt not sad during any of the Rx session.P Rx was done, PTA took pt back to room.
The post GRANTHAM Clinical Assessment And Patient Treatment Plan In Healthcare first appeared on The Nursing Tutors.