Patient Care Activities Flashcards
Orientation of the client
Do not assume they know why they are there!
Each session should have some kind of orientation
Who are you?
- What is your name?
- What is your title?
- Why you think they are there or ask them why
- What you do
Is it the right patient, diagnosis, doctor?
- review intake form/medical records
- confirm, don’t ask again
- avoid yes/no questions, you find out more when they talk
Look and listen as you assess
ECHOWS
(E)stablish rapport
- if they don’t trust you, they won’t be back
(C)hief complaint
- what brings you here?
- do you notice other things?
(H)ealth and occupational history
- comorbidities
- medications
(O)ther, psychosocial, motivation, client factors
(W)rap up
(S)ummary
- verify what you think
As the OT what are you responsible for?
Selecting appropriate assessments and tests
- based on diagnosis
* confirm the ICD 10
* develop therapeutic diagnosis
- based on prognosis
- based on other issues
Make this goal a functional outcome: “Pt will achieve full AROM in 6 weeks.”
Pt will complete UE dressing independently
Make this goal a functional outcome: “Johnny will pay attention for 10 minutes.”
Johnny will stay on task for 10 minutes to participate in story time.
Johnny will stay on task for 10 minutes with 4 or fewer prompts.
How do you communicate with clients who are deaf?
translator (person or electronic)
pictures
writing
How do you communicate with someone with a cognitive delay?
Family interview
Simplify
- grading
- pictures
- fewer steps
- repeat instructions
How do you communicate with a client who refuses or doesn’t like you?
Inform, don’t threaten
Ask why… –> interest inventory –> occupational profile
Leave
Problem oriented medical record (POMR)
Often used in education and psych
Arena eval
Problems are numbered in order of importance
Only works with a true team
Source oriented medical record (SOMR)
More traditional form of documentation
Types of documentation we typically see
Evaluations/assessments
Treatment plan/goals and objectives
Daily notes
Progress notes
Doctor notes/letters
Discharge note
Referrals
Exercise programs
Home programs
Electronic medical record (EMR)
SOAP: Subjective
The patient appeared sad
“I hate you, I hate this place.”
Pain scale
SOAP: Objective
The patient was laughing and smiling when she entered the room.
Client was offered 4 activities to promote balance and refused to attempt any.
Pain measure
SOAP: Assessment
Professional opinion based on fact
Due to the recent fall, fear may be a reason the client is not willing to attempt activities.
Client does not appear to be motivated, she seems more interested in spending time with her visitors.
SOAP: Plan
What the client is going to do in therapy in the future.
At next therapy session, we will start with 3 side support to alleviate fear.
Will discuss with daughter the need to limit visitors to afternoon so the client will attend therapy.
Blood pressure
The measure of vascular resistance to blood flow
- the more resistance, the harder the heart has to work, the higher the pressure
Systolic - top number, heart contracting
Diastolic - bottom number, heart a rest
High BP 140/90
180/120 STOP
Left arm is preferred
- can do both
- can be done in leg
- side should be documented
- legs not crossed
- sitting/standing or changing positions
Respiratory rate
Number of inhalations and exhalations in a minute
- you have to trick the patient
- count the number of ups
Shallow breathing will increase rate
With exertion you may see
- shallow breathing
- accessory muscles being used
- normal is an increase to 25-35
Temperature
Average normal body temp is 98.6-99.5
- febrile (fever) = 100 or above
Alternate “normal”
- morning or cold temps: 95-96.8
- emotional, hard work: 99.7-101
