GRANTHAM Clinical Assessment And Patient Treatment Plan In Healthcare
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.