SOAP notes

Case Study

Lab Assignment

Name:

Date:

Course:

Course Objective(s):

Goals and treatment plans

1. Explain occupational therapy to Alice in your own words

It is a branch of rehabilitative health care that aims at assessing and coming up with interventions to develop, recover and maintain the important activities of daily living; academics, hobbies, endeavors, and social activities.

2. What would you and Alice set as long-term goals?

· To train on the strength of the upper and lower extremities

· To train on prolonged standing

· To enhance independent walking

· To improve fine and gross motor coordination

· To improve standing balance

· To train on task-specific activities

3. What would long term goals you and Alice would set short term goals of occupational therapy

· To ensure independent dressing; donning and doffing of socks and shoes

· To emphasize correct ambulation with the use of strand crutches

· To train on energy conservation techniques

· To teach the patient transfers

· To educate the patient on her condition, the need for occupational therapy, and safety and precautions to observe.

4. Write out the treatment plan you would establish for Alice, including the frequency of visits

My treatment would be divided into three groups

Giving emotional support to Alice and her family members

Self-care activities involve bathing, using the bathroom, toileting, and dressing

In this portion, I will instruct and guide my patient on comfortably performing all the self-care activities while observing safety and preventing fatigue.

Productive activities will include house-keeping, cooking, and doing laundry

I will address posture, body mechanisms, gait, transfers, and precautions during performing Activities of Daily Living.

Leisure activities such as gardening and reading

I will recommend to my patient safety practices while gardening and comfort while reading the newspaper.

Strengthening and range of motion exercises- in this case, I will use functional exercises to restore strength in the upper and increase range of motion of joints

Throwing a ball

Three sets of 10 reps three times a day

Folding a large blanket

Three sets five reps three times a day

To strengthen the lower extremity and increase the range of motion of joints

Sit to stand from the chair

Three sets of 10 reps three times in a day

Balance and coordination training

Making the bed while standing

1 set of 1 rep once a day

Dusting high and low surfaces

1 set of 1 rep once a day

Ambulating around obstacles and irregular surface

1 set of 2 reps once a day

Reaching out of the base of support

3 set of 5 reps twice a day

Training on the proper use of assistive mobility devices and transfers

Lofstrand crutches

Patent education on the condition, complications, prognosis, the need for OT, expected results, safety measures, and energy conservation techniques

I will be seeing my patient three times a week

Safety and precautions

5. What safety issues do you see regarding Alice’s routine?

· The use of stall bathroom with no hand-grabs

· Inappropriate shower transfers

· The use of a narrow staircase going to laundry in the basement

· Alice overworks herself by insisting on doing all the cooking, laundry, and housekeeping by herself/

6. What things may Alice do to things differently during her routine?

· Instead of using stall showers, she should emphasize using a level access shower with hand-grabs to avoid falling.

· Appropriate shower transfer and the use of staircases to avoid falling

· The washer and dryer should be put I much accessible places that are not the basement.

· A ramp should be built in the house for Alice’s easy ambulation around the house.

· Alice needs to take a significant rest period before a change in activities.

· Alice should also ask for help to avoid fatigue as a result of overworking herself

Self-care/ Work/Leisure

7. What changes could you suggest to make Alice’s dressing routine easier?

Firstly, Alice should consider wearing clothes that do not require much time to iron and put on. Secondly, she should only wear socks when necessary, and lastly, she should wear shoes that are easy to put on and remove, such as sandals and mules. She should sit down while dressing up.

8. What changes could you suggest for her bathing routine?

Instead of using a stall shower, a level access shower should be built to accommodate Alice’s condition. Additionally, instead of showering while standing, she can sit on a comfortable shower chair during bathing. Hand-grabs can be constructed in the bathroom to help with support and stability. Finally, she should practice safe and appropriate transfers in and out of the shower; she should place the crutches upright close to her in the shower, not outside, and inhibit her from pulling herself using the door and shower faucet.

9. What techniques would you teach Alice to help her deal with her fatigue?

· To plan her day and use routines

· Prioritize her tasks and alternate hard tasks with easy tasks

· Sit down while performing tasks like cooking and laundry and avoid a task that requires prolonged standing

· Allow enough time to accomplish the task

· Practice pursed-lip breathing

· Sit down during toileting, showering, and dressing

· Spread cleaning activities throughout the week

· Take rest after performing tasks

· Avoid overworking herself

10. What alternative could you suggest to Alice if she feel too fatigued by late afternoon to prepare the evening meal?

She could buy ready-made food to avoid cooking.

11. What could Alice do for meals if her symptoms are interfering with her ability to cook safely?

She could buy food that is already cooked or ask for help from her husband and her niece.

12. Alice loves to garden, and she misses being able to get into the yard to tend to her flowers. She asks for a suggestion to help her resume her hobbies.

· She should break down farming tasks into stages; section the garden into small potions.

· She should raise her flower beds to avoid assuming the uncomfortable posture

· Use slow-release water irrigation to reduce the frequency of watering flowers.

· She could sit for gardening tasks that can be done while sitting

· Reduce heavy lifting such as lifting manure in large volume

· She could adapt using electrical gardening tools which require less effort, such as an electric mower and trimmer.

· Use lightweight and gardening tools with long handles

· She could also employ a gardener to help her with tending for her flowers.

13. Alice also likes to read while sitting in her reclining chair but gets tired from holding the newspaper open. She says she misses out on the news and asks if you have any suggestions

She could get a proper reading surface where she can comfortably read the news while maintaining a good posture without holding it.

Equipment/Adaptations

14. What adaptive equipment might Alice benefit from to increase her independence and safety?

· Cooking tools- lightweight pots, electric cans, and jar openers

· Housekeeping tools- long-handled duster sponge, reacher to grab objects from high shelves, and wheeled cart to carry cleaning and laundry supplies

· Bathroom aids- shower chair, hand-grabs, non-skid bath map, electric toothbrush, and soap pump dispenser.

· Grooming tools– Velcro tabs, zippers pull, elastic shoelaces, button hooks and combs, and brushes with large padded handles for easy grasping

· Walking aids- braces

15. Using medical/therapy catalogue, determine the total cost of these items

$450

16. Prioritize the equipment she needs the most if she only has $200 to spend on supplies

· Lightweight pots

· Wheeled cart to carry supplies during cleaning and laundry

· Shower chair

· Handrails in the bathroom

· Non-skid bathroom mat

· Braces

17. What could you do to adapt her environment cost-free?

· Putting an extra chair which is suitable she has in the shower to act bas shower chair

· Remove clutter from the floor that may predispose to fall easily

· Put the laundry machines in a more accessible area

Neuromusculoskeletal

18. Write out a home exercise program for Alice

Strengthening exercises for the upper extremities and lower extremities

Throwing a ball

Three sets of 10 reps three times a day

Folding a large blanket

Three sets five reps three times a day

Sit to stand from the chair

Three sets of 10 reps three times in a day

Balance and coordination training

Making the bed while standing

1 set of 1 rep once a day

Dusting high and low surfaces

1 set of 1 rep once a day

Ambulating around obstacles and irregular surface

1 set of 2 reps once a day

19. How will you treat the sensory deficits on her hand?

Through sensory integration therapy, which involves specific body movements, resisted body biomechanics, and brushing of the skin to restore sensation.

Psychosocial

20. Why might Alice have been reluctant to engage in occupational therapy? What functional activities could you recommend to work on UE strength and ROM?

Alice was reluctant to engage herself in occupational therapy because she did not see the need for it. She could perform most of her tasks, and she thought she was sufficiently and effectively productive.

Functional activities to work on strength and ROM of UE are folding large pieces of clothes and wearing weighted wrist cuffs while doing tasks that involve the hands, such as folding laundry, meal preparation , using a computer, and dressing.

Patient/Family Education

21. Alice’s husband comes home one day during your session. He asks what he can do to help Alice. She shouts, “Nothing! I’m fine. This is my problem”. What do you tell him?

To be patient with Alice and show her emotional support.

Situations

22. You arrive at Alice’s house for a visit, and she calls for you to come in. As you enter the kitchen, you find Alice carrying a chicken potpie with one hand and trying to hold onto the counter for balance with the other. The food is obviously hot as the kitchen has a fresh-baked aroma. How do you address these safety concerns with Alice? List several ways and her possible reaction to your comments

I will let her know the danger she is putting herself in; falling and the hot food would spill on her, causing burns and other secondary injuries. Then I will give her alternative ways to handle hot pots, which we might improvise or recommend buying assistive devices such as trolleys to help her carry food around.

Alice’s possible reactions include:

“I am fine; I have been doing this for so long!’ “I can comfortably carry the pot without straining!”

“The pot is not that hot!”

“I will be careful next time!”

“It is not that bad! Is it? ”

23. Assume that after you mention this to her, she becomes defensive and tells you she’s not a child. How do you deal with her feelings?

I will give her the chance to express what she feels about my safety concerns and then try to find the most effective solution as a team.

24. You arrive at Alice’s home, and she is visibly shaken. She tells you she had fallen about 45 minutes ago and just got herself up onto the kitchen chair. She tells you feels fine, and she’s just “mad at herself” for getting stuck between the counter and the kitchen table. She says, “It could happen to anyone!”What do you do? Alice tells you not to mention the fall to the PT or her husband. What do you say?

Firstly, I concur with her that falling on the kitchen floor could happen to anyone. Then assess for injuries and refer in case of any complication. Thirdly, we will discuss ensuring she is safe while cooking and moving around in the kitchen, and removing clutter that may make her fall. I will talk her into telling her PT and husband the falling scenario as it is important in her rehabilitation program.

25. You arrive at Alice’s house for a scheduled visit. There is no answer at the door, and it is locked as always. She has never missed a visit before. You are worried she might have fallen and is unable to get to the door. What do you do?

I will try calling her by her name loudly; if she does not answer, I will call her phone. If Alice fails to answer her phone, I will try reaching her husband to ask about her whereabouts.

26. Suppose you arrive at Alice’s home and there is no answer when you knock, but the front door is unlocked. You are fearful she has fallen. Do you go in without being invited? Please explain why or why not

I will go in and try to find out what might be the issue. This is because Alice might have fallen and hurt herself and has not reached for help.

27. You do go in and find Alice on the bathroom floor. She says she has pain in her shoulder and tells you to help her up. What do you do?

I will help her stand then assess for injuries and the painful shoulder. In case of a medical emergency, I will call an ambulance and rush her to the hospital for further investigations and management. After her pain has gone away, we learn together the safety measures to observe in the bathroom and correct shower transfer.

Discharge planning

29. You have met all your goals with Alice and plan to discontinue occupational therapy. However, because of the nature of her disease, you know that it is likely she will need further intervention. How do you explain to her the need to discontinue OT?

I will extensively explain to Alice that we had achieved all the short-term and long-term goals we had, and it was time to terminate treatment to avoid unnecessary financial strain. However, I will let her understand the pathophysiology, complications, and prognosis of her condition. Lastly, I will ask her to observe safety and report any new symptoms she presents with.

30. How can you be assured she’ll get the OT interventions needed once that situation arises?

Once reoccurrence occurs, Alice might not wish to go through OT interventions again because of her initial attitude towards occupational therapy.