DIXIE REGIONAL ACUTE REHABILITATION UNIT TEAM CONFERENCE and INDIVIDUALIZED OVERALL PLAN OF CARE SUMMARY

Transcription

1 DIXIE REGIONAL ACUTE REHABILITATION UNIT TEAM CONFERENCE and INDIVIDUALIZED OVERALL PLAN OF CARE SUMMARY Conference Date: Rehab Admitting Diagnosis: Comorbid Conditions: Current Medical Prognosis: New Admit who is appropriate enough for Acute Rehabilitation and able to tolerate 3 hours of therapies who is stable and expected to make progress. Bowel: Bladder: Pain: Cardiac: BP HR Respiratory: Nutrition: Falls/Falls Risk: Skin: Other: Primary Care Physician and/or physician to follow on discharge: Barrier: Acute Pain r/t surgery Interventions: Modalities, relaxation/breathing techniques, heat, cold, repositioning, administer pain medication prior to therapy to increase participation, monitor pain intensity on scale, and reassess pain. Monitor for sedation. Educate on pain expectations. Anticipate needs. Goal: Patient s pain will be managed for full participation in therapy during rehab stay. Barrier: Falls/Fall Risk Intervention: Falls precautions, staff to train patient/family in falls prevention, call light in reach, bed alarm, hourly rounding, across from nurse s station. Goal: Patient will verbalize/demonstrate essential concepts of good balance/safety awareness during self-care and mobility skills with independence. Patient will not receive injury related to fall during rehab stay. Barrier: Body Mechanics Intervention: Staff will educate patient on self-care positioning, bed positioning/re-positioning, reinforce proper sequencing and positioning for transfers and mobility. Cue patient to move center of gravity over feet prior to sit-to-stand or stand-to-sit. Goal: Patient to demonstrate correct body mechanics with all self-care activities and mobility with no verbal cues. *50054* Cr Pln50054

2 Barrier: Balance Intervention: Staff to encourage patient to not use hands to pull self-up (i.e. grab bars, furniture, walls). Goal: Patient will demonstrate proper recovery strategies if experiencing a loss of balance. Barrier: At Risk for Alteration in Skin Integrity Intervention: Skin checks daily. Encourage proper hygiene and nutrition and hydration. Increase mobility. Teach patient pressure relief techniques. Ted hose on in AM and off in PM. Staff to educate the patient on ARU Hydration program. Assist the patient to turn every two hours when in bed. Goal: Patient s skin integrity will be maintained during rehab stay. Barrier: At Risk for Constipation/Diarrhea Interventions: Medications as ordered, encourage mobility, encourage proper fluids and hydration, offer prune juice, encourage patient to add fiber to diet. Staff to educate patient on ARU Hydration Program. Education on constipation in relation to pain medication, and therapy, and hydration, and diet. Goal: Patient to establish regimen of bowel routine during rehab stay. Barrier: Activity Intolerance Interventions: Space therapies, allow rest between therapies, and encourage patient to sit up between therapies to increase endurance. Monitor adequate fluid intake, assess pain, educate, and assess v/s. Goal: Patient s activity intolerance will improve during rehab stay. Barrier: Deep Vein Thrombosis Prophylaxis Interventions: Bilateral knee high ted hose on in am off in pm. Goal: Patient s risk for DVT will be reduced during rehab stay. Barrier: Accessible Community Resources Interventions: SW/CM to assess support system and needed resources for safe discharge home. Goals: Patient will discharge to appropriate level of care with accessible resources safely. All Goals expected to be met by discharge.

3 Functional Progress (FIM instrument): Function Initial Date Comments Bladder Bowel Bathing Upper Extremity ADLs Lower Extremity ADLs Toileting Transfers Mobility Tinetti (Balance Test) Problem Solving Memory FIM is a trademark of Uniform Data System for Medical Rehabilitation, a division of UB foundation Activities, Inc.(UDSMR). The FIM data set, measurement scale and scoring levels referenced herein are the property of UDSMR Reprinted with permission. FIM Levels Total Assist Maximal Moderate Minimal Supervision Modified Assist Assist Assist Independent Anticipated therapeutic interventions: PT Expected Intensity: minimum of 90 minutes a day(# of mins. per day by discipline) Frequency: 5 days a week (# of days per week by discipline) Complete Independence Anticipated therapeutic interventions: OT Expected Intensity: minimum of 90 minutes a day (# of mins. per day by discipline) Frequency: 5 days a week(# of days per week by discipline) Anticipated therapeutic interventions: SLP Expected Intensity: minimum of 60 minutes a day (# of mins. per day by discipline) Frequency: 5 days a week (# of days per week by discipline)

4 Areas of Medical Progress: (may include skin, medication, disease management, nutrition hydration or other) See Above RETURN TO LIFE OUTCOME: Functional: The patient will be with basic self-cares and functional mobility. Estimated Discharge Date: Estimated Length of Stay: Recommended Destination: Social/Spiritual/Recreational/Community interests of the patient: Patient Community reintegration goals: Patient potential to reach goals for Community Integration: TBD Special Needs Identified (may include, equipment, home assessment family/caregiver training, therapeutic pass, family conference, transitional living arrangement, and/or community integration): Skills Passed Off Floor Recovery Car Transfers Stairs Outside Surfaces Community Access/Outing Safety Issues and Driving Sitter Home evaluation Equipment Needs Home exercise Program Caregiver Training Family Conference Education: Medication, diet, diagnosis, routine. Education on Coumadin and MD following Follow up care Recommendations by the ARU TEAM Comment or Date Completed To be discontinued prior to patient discharging To be determined if appropriate To be determined To be given by PT or OT TBD with Caregiver Can be arranged if needed To be ongoing with nursing and staff Not taking Coumadin 2 weeks post discharge with PCP and Dr. Vroenen? Attendants of meeting:

5 OT: PT: Nursing: SLP: Recreation: Psychology: Dietitian: SW: Nurse Manager: CM: Other: Other: By signing this form I am in concurrence with the above treatment and plan of care as discussed by the above interdisciplinary team. Physician: Date: Time: This plan has been reviewed with me in a language I understand and I have had the opportunity to have input in its development. Patient/Significant Other Date Time Interpreter Date Time Plan reviewed by phone with by Date Time