Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Foundations of Patient Care > Final Documentation things > Flashcards

Final Documentation things Flashcards

1
Q

A

A

Pt. requires mod A with stair climbing activities
due to limited ROM in both knees

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

S

A

Pt reports inability to negotiate his stairs PTA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

S

A

 States his goal is to return to work ASAP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

O

A

Pt received a hot pack to the low back for 15 min followed by soli tissue mobilization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What’s in the objective section?

A
  •  Choice can be based on “S”
  •  Tests and measure results
  •  Functional status
  •  Treatment interventions / events
  •  Education / exercises
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

A

A

Pt. is an excellent candidate for instruction in WC mobility

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Types of notes

A
  •  Initial evaluation
  •  Daily note
  •  Progress / interim note
  •  Goal writing note
  •  FIM scores
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

P

A

Pt. will be seen BID for gait and transfer training
and LLE strengthening exercises

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

O

A

 Strength: 4/5 proximally in B UE’s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

P

A

Pt will be able to go from sit to stand independently within 10 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

O

A

Strength: R LE proximal strength 2/5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

O

A

 Pt able to recall 3/3 THR precautions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

AROM

A
  •  Independently performed
  •  Contraindications
    •  Unstable fracture site
    •  Severe acute inflammation
    •  Medical instability
    •  Severe pain / joint swelling
  •  Benefits
    •  Maintain ROM
    •  Improve strength, endurance, & flexibility
    •  Increase local blood flow
    •  Increase sensory input
    •  Reduce effects of disuse
    •  Prevention of blood clots
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

O

A

Pt has a Stage l pressure ulcer on the superior potion of the sacrum

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

ROM rationale

A
  •  Prevent contractures
  •  Provide elongation of
  •  Muscles
  •  Ligaments
  •  Tendons
  •  Joint capsules
  •  Provide sensory stimulation
  •  Increase strength (A AA R ROM)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

A

A

Pt is at increased risk for sacral pressure decubati due to poor bed mobility and sensation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

A

A

Pt. is an excellent candidate for prosthetic
training with a free knee unit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

A

A

Pt will benefit from work station evaluation to
improve sitting posture and minimize neck pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What’s in the Plan section?

A
  •  Treatment plan
  •  Goals
  •  Discharge planning
  •  Referral
  •  Recommendations
  •  Equipment order
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

PROM

A
  •  Dependent for joint movement
  •  Severe weakness / paralysis
  •  Severe neurological impairment (coma)
  •  Around a healing fracture
  •  Painful conditions associated with AROM
  •  Importance for future functioning
  •  Limitation for strengthening / prevention of atrophy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

P

A

Pt. will be independent in donning and doffing their prosthesis in 1 wk.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Reasons for documentation

A
  •  For reimbursement
  •  Communication with others
  •  Legal document
  •  Quality assurance
  •  Retrospective research
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

P

A

 Will provide training in going from supine to sit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

A

A

Safety in unsupported sitting is decreased due to trunk weakness

25
Q

Types if Range of Motion

A
  •  Active
  •  Active –assistive
  •  Resistive
  •  Passive
26
Q

O

A

Gait: Amb. with RW, WBAT on L LE for 125 ft. requiring CG

27
Q

P

A

Pt. will receive pulsed US to the R ant shoulder
with 1.5 wts/cm2 and 1 MHZ, 50% duty cycle for
10 min

28
Q

A

A

Pt will progress much more quickly when his WBing status is upgraded to WBAT

29
Q

A

A

Practice pattem Musculoskeletal G: Impaired joint mobility, muscle perfonnance and ROM associated with fracture

30
Q

P

A

Will educate the patient`s family on inspection ofthe foot integument

31
Q

P

A

Pt. will be mod I with stair climbing using one rail and a SC for ten 6” steps within 2 wks.

32
Q

A

A

Pt exhibits neck pain due to a forward head posture and poor set up of her work environment

33
Q

AAROM

A
  •  Assistance with outside forces during voluntary contractions
    •  Pain
    •  Weakness
    •  Motor control deficits
    •  Abnormal muscle tone
  •  Types of assistance
    •  Manual
    •  Mechanical
    •  Gravity
34
Q

O

A

 Flexibility: R SLR to 40o

35
Q

What’s in the Subjective section?

A
  •  Information from patient, family members, etc.
  •  Related to c/o
  •  Home set up
  •  Social support
  •  Equipment
  •  Goals
  •  Medical history / medications
36
Q

O

A

Pt. received training in lateral transfers with a sliding board

37
Q

O

A

. Pt requires min A to go from sit to stand

38
Q

A

A

Practice pattern Integumentary C: Impaired integumentary integrity associated with partial thickness involvement and scar formation

39
Q

O

A

 Vitals: HR 83 / BP 132/85 / Sp02 97%

40
Q

S

A

Pt c/o R knee pain while descending stairs

41
Q

A

A

R shoulder impingement syndrome and pain
limits the pt. during overhead reaching activities

42
Q

S

A

Pt states that he would like to be able to nm the NYC marathon

43
Q

S

A

 Pt. c/o L wrist pain

44
Q

O

A

Requires min A to for static sitting balance

45
Q

P

A

Pt will receive a wide based quad cane upon discharge

46
Q

What’s in the assessment section?

A
  •  Clinical judgment based on “S” and “O”
  •  Usually related to function
  •  Rationale for interventions
  •  Patient classification in practice patterns
47
Q

S

A

Pt reports that he will not have any stairs when going into his house

48
Q

A

A

Pt. will require less assistance with lateral transfers as strength in B UE’s improves

49
Q

P

A

. Pt will receive OPD therapy 3x’s a week for 3 weeks

50
Q

S

A

Pt reports that home bathroom doorway is too narrow for WC use

51
Q

P

A

Will instmct the patient in ace wrapping for their R residual limb

52
Q

S

A

Reports increased LBP during prolonged sitting

53
Q

S

A

States onset of weakness in both legs in July 2012

54
Q

P

A

Pt. will receive a HEP for increasing R shoulder
AROM

55
Q

O

A

 ROM: L knee PROM increased to 5 to 85o

56
Q

P

A

Pt. will be referred to brace clinic for
assessment of proper shoe wear

57
Q

P

A

Pt. will receive a RW prior to D/C and will be
followed by the Hunter Home Care Agency for
further therapy

58
Q

S

A

Pt. reports inability to go from sit to stand from low surfaces

Foundations of Patient Care (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions