Thursday, February 25, 2016

S: Client stated she was feeling tired today. She reported wearing her splint 1 hour
daily and her husband did joint mobilizations with her throughout the week.
O: Client was seen in the Life Skills Clinic for 1 hour. She was accompanied by her
husband. Client required modA for balance and VC for foot placement for transfer
to/from mat for joint mobilizations. Client flexed, extended, adducted, and abducted
shoulder and extended wrist with maxA. Fingers extended with modA. Client
prepared and cooked muffins using her affected arm as a stabilizer with handling
and VC to open and place her hand. Client stabilized while opening ingredients,
measuring ingredients, and holding baking tray. During cleanup client used her
affected arm for weight bearing. She bore weight on her extended arm minA to
maintain balance in standing. She bore weight on her forearm with handling and VC
to maintain weight bearing while cleaning with unaffected arm for approximately 3
minutes.
A: Client required modA for transfers due to general weakness, decreased balance,
and painful BLE. VC were provided because she pivots with improper foot placement
which causes pain and poor body mechanics. Clients finger extension was markedly
improved because of her frequent use of her SaeboStretch splint the previous week.
She needed handling to maintain positioning due to high tone which restricts active
extension of her elbow, wrist, and fingers. Client weight bearing in standing was
difficult for her because she was unable to fully extend elbow and wrist even with
handling which made weight bearing uncomfortable. She switched to sitting to
decrease the required elbow extension and was able to weight bear on her forearm.
She required handling and VC to sustain weight bearing due to high tone.
P: Client will continue with skilled occupational therapy 1x/week for 3 visits to
increase use as her RUE as a stabilizer and for weight bearing to increase her
independence in occupations. Client will continue to wear her SaeboStretch splint
daily for at least 1 hr/day. Caregiver will do joint mobilizations daily.
LTG 1: By d/c, CK will use her affected arm as a stabilizer during meal
preparation with no more than 3 verbal cues.

STG 1: In 3 weeks, CK will use her affected arm to prevent items from falling
off tabletop with no more than 2 physical cues.

STG 2: In 6 weeks, CK will (I) initiate use of her affected arm during meal
preparation.

LTG 2: By d/c, CK will safely transfer to/from w/c with minA for ADL participation.

STG 1: In 4 weeks, CK will correctly position feet for transfer with no more
than 3 verbal cues for ADL participation.

STG 2: In 6 weeks, CK will safely transfer to/from shower chair with modA.

LTG 3: By d/c, CK will use her affected arm as a weight bearer during

transfers and functional activities with no more than 3 VC to increase her

occupational independence.

Melanie Francis, OTS

02/26/16