PRIOR LEVEL OF FUNCTION
Prior to the current exacerbation of the illness, the patient needed no assistance (was independent) with basic activities of daily living (BADLs) including household mobility. IND WITH GETTING IN/OUT OF HOUSE, IND WITH TRANSFERS, GROOMING, BATHING, LAUNDRY, SHOPPING, TRANSPORTATION.
PAIN
LOWER BACK AT 4/10; WORST WITH COLD/RAINY WEATHER, WEIGHT BEARING, TRANSFERS; BETTER WITH REST, MEDICATION, DIVERSION
Goals Strength Intervention
PHYSICAL THERAPY TO ESTABLISH/UPGRADE HOME EXERCISE PROGRAM AND PROVIDE EXERCISES DESIGNED TO RESTORE FUNCTIONAL STRENGTH AND ROM. PT MAY ALSO PROVIDE SOFT TISSUE AND JOINT MOBILIZATION TO REDUCE JOINT DEFORMITY/PAIN AND INCREASE FUNCTIONAL RANGE OF MOTION. PRE EXERCISES WITH THERABAND PROGRESSING FROM ORANGE-RED-GREEN-BLUE FOR 1-2 SETS OF 15-20 REPS EACH TO IMPROVE MUSCLE STRENGTH IN EXTREMITIES.
Goals Balance Intervention
PHYSICAL THERAPY TO ESTABLISH/UPGRADE HOME EXERCISE PROGRAM AND PROVIDE EXERCISES DESIGNED TO RESTORE FUNCTIONAL STRENGTH AND ROM. PT MAY ALSO PROVIDE SOFT TISSUE AND JOINT MOBILIZATION TO REDUCE JOINT DEFORMITY/PAIN AND INCREASE FUNCTIONAL RANGE OF MOTION. PRE EXERCISES WITH THERABAND PROGRESSING FROM ORANGE-RED-GREEN-BLUE FOR 1-2 SETS OF 15-20 REPS EACH TO IMPROVE MUSCLE STRENGTH IN EXTREMITIES.
Goals Gait Intervention
PHYSICAL THERAPY TO ESTABLISH/UPGRADE HOME EXERCISE PROGRAM AND PROVIDE EXERCISES DESIGNED TO RESTORE FUNCTIONAL STRENGTH AND ROM. PT MAY ALSO PROVIDE SOFT TISSUE AND JOINT MOBILIZATION TO REDUCE JOINT DEFORMITY/PAIN AND INCREASE FUNCTIONAL RANGE OF MOTION. PRE EXERCISES WITH THERABAND PROGRESSING FROM ORANGE-RED-GREEN-BLUE FOR 1-2 SETS OF 15-20 REPS EACH TO IMPROVE MUSCLE STRENGTH IN EXTREMITIES.
EVAL KNEE ORTHO
SUBJECTIVE
PATIENT STATED HER LEGS FEEL WEAK AND SHE GETS TIRED EASILY.
MMT
GROSS MUSCLE STRENGTH IN RIGHT HIP 3/5 LEFT HIP 3/5 IN RIGHT KNEE 3/5 LEFT KNEE 3/5 IN RIGHT ANKLE 4/5 LEFT ANKLE 4/5
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Goals Strength
Patient will improve bilateral LE muscle strength by at least 1.5 point on the MMT to enable independence in ADLS and gait BY 4 WKS
Goals Balance
PATIENT TO DEMONSTRATE REDUCED FALL RISK - SHORT TERM GOAL- IMPROVE STATIC STANDING BALANCE TO GOOD+, REMOVE THROW RUGS, CLUTTER FROM LIVING AREA BY 2 WKS/ LONG TERM GOAL- PATIENT'S SPOUSE WILL PROVIDE SUPERVISION WHEN AMBULATING OUTDOORS TO DECREASE RISK OF FALLS BASED ON SOB AND FATIGUE BY 4 WKS. IMPROVE DYNAMIC STANDING BALANCE TO GOOD AS EVIDENCED BY IMPROVED TINNETTI SCORE OF >21/28 to enable resuming PRIOR LEVEL mobility. Patient will reduce the risk for falls to a low risk as indicated by improvement in TUG scores to scores that are less than 12 seconds to re-enable INDEPENDENCE IN mobility BY 4 WKS
Goals Gait
Short term goal : Patient will ambulate for at least 50 ft on even surfaces with a independence using walker to enable resuming household mobility by 2 wks LONG term goal : AMBULATE 250 FT IND SAFELY ON LEVEL SURFACE TO ALLOW ACCESS TO VEHICLE FOR TRANSPORT FROM HOME BY 4 WKS
Goals Transfers
PATIENT /CAREGIVER WILL DEMONSTRATE SAFE TRANSFERS USING APPROPRIATE BODY MECHANICS AND EQUIPMENT - SHORT TERM GOAL- COMPLETE SIT-STAND SAFELY PUSH UP FROM ARMREST CONSISTENTLY BY 2 WKS / LONG TERM GOAL- IND WITH TRANSFERS SAFELY, PT WILL BE ABLE TO GET UP FROM FLOOR LEVEL WITH SUPERVISION AS A FALL RECOVERY STRATEGY BY 4 WKS
Goals Pain
Patient will improve Knee pain interference with ADLs from frequent to INTERMITTENT in order to resume independence in household mobility by 3wks.
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PT ORTHO KNEE EVAL
PATIENT NAME:
SELECT AGE: GENDER ASSISTIVE DEVICES
PATIENT AND DISCHARGED TO HOME ON
PMH INCLUDES STRENGTH LEFT OR RIGHT
TINNETI BALANCE TINNETI GAITTUG:
LIVING SITUATION LIVES WITH A
