Occupational therapy treatment plan: treatment intervention
Assessment
Patient is a 72 year old woman who presents with decreased strength/endurance, impaired balance, ADL/IADL deficits, pain due to recent hospitalization for L hip arthroplasty. Pt goals for rehab are to return home, to be able to drive, and to resume her life as it was before the surgery, including independence in all ADLs and IADLs. She said she wants to walk without a cane and be able to get up and down stairs without pain. Patient will benefit from OT services to address current functional deficits to maximize pt potential to return to PLOF. Pt is at risk for falls and further functional decline without OT services.
Plan of Care (POC)
Problem List :
ADLs
Pt is Max A for LB dressing 2/2 limited functional use of LLE due to L THR and B UE pain
Pt is Min A for UB dressing 2/2 decreased muscular endurance and B UE pain
Pt is Max A for LB bathing c AE 2/2 limited functional use of LLE due to L THR and B UE pain
Pt is CGA for UB bathing c AE 2/2 B UE pain
Pt is Min A for toileting c AE 2/2 B UE pain
IADLs
Laundry: Pt has inability to navigate narrow staircase to basement 2/2 left THR resulting in decreased LE ROM, strength, endurance, and increased pain in LLE.
Driving: Pt is mod assist for car transfer 2/2 left THR resulting in decreased LE ROM, strength, endurance, and increased pain in LLE and both shoulders.
Safety and emergency maintenance: Pt is a fall risk (particularly at home alone with stairs) 2/2 left THR resulting in decreased LE ROM, strength, endurance, and increased pain in LLE.
Functional Mobility
Pt is Min A for sit to stand transfer c RW 2/2 UE muscular weakness and limited functional use of LLE due to L THR
Pt is Mod A for toilet transfers c RW 2/2 UE muscular weakness and limited functional use of LLE due to L THR
Pt is Mod A for tub transfers c AE and RW 2/2 UE muscular weakness, decreased standing endurance, and limited functional use of LLE due to L THR
Strengths (List):
Attend same church for 35 years (religious)
Sister who lives within walking distance to home
Play cribbage online 1x/week with 3 women from church
Volunteer at local library to read to children
Static/dynamic balance
Positive attitude
Long Term Goals (Time Frame: 1-2 weeks)
By discharge, pt will complete ADLs Min A c AE PRN to increase functional independence and prepare for discharge.
By discharge, pt will complete functional transfers CGA c AE and RW PRN to increase functional mobility and prepare for discharge.
Short Term Goals (Time Frame: 1 week)
Within 2-3 sessions, pt will complete UB dressing CGA c AE and RW PRN in order to increase functional self-care independence.
Within one week, pt will perform LB dressing with Min A using assistive device and cuing as necessary in order to increase functional self-care independence.
Within one week, pt will perform sit to stand and stand to sit transfers with CGA using assistive device (RW) and cuing as necessary in order to increase functional mobility.
a.Within 2-3 sessions, pt will complete toilet transfers Min A c AE and RW PRN to prepare for discharge
b.Within 2-3 sessions, pt will complete tub transfers Min A c AE and RW PRN to prepare for discharge.
