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.
Why is documentation important?
It is a legal document.
It’s how we make money.
Primary mode of communication
It it isn’t documented, it didn’t happen
There’s a 3 year period for lawsuits.
General documentation knowledge
Keep it factual
Only document the important stuff, keep it simple
Make sure it flows, shows progress, and why you are making certain decisions
Document on time
Be legible
Only use approved abbreviations
Leave nothing blank
If you cosign for a COTA, know what you are signing
General patient eval
Gather subjective and objective information
Find the primary problem
Find the cause
Previous level of function and treatment
Current level of function
Pain
Medication
General areas to assess
General appearance
Skin
Ambulation or posture
Mobility
Balance, coordination, control
- static and dynamic
Devices
Joints
Deformities
Edema
Pulse
General tests
MMT
AROM, PROM, AAROM
- goniometer
- eyes
- computer
Joint integrity
Reflexes
Cardiopulmonary
- pulse
- BP
- respiration
Functional vs. physical
Mental and cognitive
Developmental
Things to consider
X-ray
MRI
Psychological testing
Hearing
Patient and family education
Patient should always know diagnosis.
Family doesn’t always have to know.
If pt has a DNR, make sure to have a copy.
HIPAA
Health Insurance Portability and Accountability Act
Notice of privacy
No information that is identifiable.
- sign in sheets
- room number
- name
Designed to
- give clients access and control over health information
- protect against the use and release of health information
- establish safeguards to assure privacy
What happens if you violate HIPAA?
Single violation - $100 fine
Multiple violations of an identical requirement in a single year - up to $25, 000 fine
Wrongful disclosure - 1 year in prison and $50,000 fine
Wrongful disclosure under false pretenses - 5 years in prison and $100,000 fine
Wrongful disclosure with intent to profit or harm - 10 years in prison and $250,000 fine
Communicating with people with disabilities
Speak to the person
ID yourself to the blind
Try to get on eye level
Don’t lean on wheelchair
Don’t patronize
Listen and wait for answers
Don’t assume
Wait to see if help is needed
Ask don’t stare
General safety
If your gut is worried, stop
Ask for help
Do your research
Wash your hands
Enough space
Watch elbows and fingers
See where you are going
Check equipment and keep record
Secure placement of stuff
Keep area clear
Never leave patient unattended
Protect patient
- watch catheters
Set up before patient arrives
Work with qualified staff
Keep dangeorus equipment locked up or out of general population
Vital signs
Take them at the start of therapy process for a baseline, then as needed or dictated by diagnosis.
Heart rate/pulse
Bloop pressure
Respiratory rate
Oxygen saturation
Temperature
Weight
Height
Pain
Why?
- monitor as part of rehab
- continue therapy
- halt therapy
- halt therapy and refer
Pulse/heart rate
Basal heart rate - over an extended period of time
Resting heart rate - rate without stress
Maximal heart rate - higher it should be on exertion
Target heart rate - rate you should achieve during exercise
- usually between 60-80% of max
Bradycardia - RHR below 50
Tachycardia - RHR above 70
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
BP red flags
Systolic doesn’t rise with increased activity
Systolic drop of more than 10mmHg
Systolic of greater than 240mmHg
Increased diastolic of 20mmHg
BP position
Bladder should cover 80% of arm
Place 2-3cm above the antecubital fossa
Relax arm
Pump bulb until brachial pulse stops
- watch for kinks or bends
Place stethoscope over the brachial artery
Slowly release pressure
First bump is systoic, last is diastolic
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
Oxygen saturation
Fingers and toes are the last point of oxygenation
Normal is 95-100%
* 91-94: concern, requires monitoring
* 85-90: low blood oxygen, may need support during activity
* 80-85: low blood oxygen, may impact cognition, support during activity
* below 80: severe hypoxia, hospitalization
* below 70: acute danger to life
Fake nails or nail polish may affect reading
Pain measurement
Visual analog
Questionnaires
Ransford pain diagram
Anthropometrics
Weight and hight
BMI
- obesity 30 and above
Concern when there’s a change of 2 standard deviations more or less
