University:
American Career College
Course:
NURS112 | Fundamentals of Nursing
Academic year:

2021
Views:

190

Pages:

2
Author:

kundgetanufv

FRANK SOAP Subjective: Frank says he is indep in tasks “I do everything for myself anyway”. He expresses difficulty with reaching his feet “I always struggle with my socks and shoes...I think I might try slippers on today” Objective: Purpose was to complete PADL assessment. Pt t/f from the bed using O2 and a 4WF. Pt tried multiple attempts at lifting his pelvis from the bed before being successful. Pt used 4WF during his walk to shower room and had to stop to rest. Pt sat down on the shower chair and took several deep breaths. Pt used the handle of 4WF and grabrail to stand upright unsteadily and untie his robe. Pt turned the tap on, adjusted the temp and used a handheld showerhead to rinse himself. Pt towelled himself off and for LL used different ways for example, bending over his knees and lifting his leg up to reach his feet. After this attempt, he drops it on the floor to wipe his feet. Pt dressed himself in his undergarments, buttoned and belted up his pants and put his shirt on. He expressed his fingers were sore when buttoning up his pants. Pt applied his deodorant and took several deep breaths after putting on his O2. Pt slipped both socks on his feet but needed the OT’s assistance with pulling them up over his ankle. Pt wanted a rest before walking back to his bed. Pt was unsteady and needed OT’s hand support when walking back. OT provided sup and safety reminders for example “Be careful when standing up”. OT provided encouragement during shower task for example “Take your time, you’re doing well”. OT assisted with shower toiletries prep and handed them to Pt. OT also assisted by putting the 4WF in the arms reach of Pt. n Assessment: Pt experiences SOB when moving supine to sitting to standing. Pt also holds his breath when doing difficult tasks such as removing the robe, wiping the towel on LL and bending over his knees to towel off his feet. Pt is aware of his difficulties in reaching far down towards his feet. Pt has unsteady balance when both hands are not holding onto something and shows shuffling gait when mobilising on 4WF. Seems a bit distressed when he closes his eyes and focuses on his breathing. For example, after drying his feet off. Plan: Emphasise pursed lip breathing techniques 10 reps x 1. Include practice in shower task: removing robe, wiping soap and towel on LL. Implement the following assistive equipment: Shower stool Long-handled reacher Discuss drawstring or elastic band pants instead of pants with belts/buttons for informal dressing.