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Guillain Barré

More Progress Notes

September 16, 1996

Smith, Linda
12-34-56-78

Case conference No: 5
Date: 9-16-96
Adm. Date: 7-15-96
Case Mgr: Braddock
Critical Path: NPF Changed to: ____ on _____
Next CIC: 9-16-96
Funding Source: Primary Gencare, UMC HMO Secondary
Admission Level: II Changed to I on 8-19-96
Discharge destination: Home with parents
Estimated Date of Discharge: 9-18-96
Patient Status for Week of 9-9-96 to 9-16-96

Health Status: Ms. Smith is a 37-year-old female diagnosed with Guillain-Barré, following a two week history of tingling in hands and feet then progressively weakened with inability to stand independently or meet self care needs. She was admitted to Rusk Rehabilitation Center on 7-15-96. Currently, she is medically stable.

Physical: Ms. Smith is completing a home exercise program in anticipation for discharge planning with assistance from physical therapy. She continues to participate in education regarding safety and mobility. She requires cues for safety to complete a stand pivot transfer and asks for assistance as necessary. Ms. Smith's physical therapist will address appropriate techniques to get up off the floor in an event of a fall. She is independent in all bed mobility tasks. She is able to ambulate 150 feet using a wheeled walker with contact guard assistance and left hip hike and slight bilateral foot drop. Gait deviations increase with fatigue. Ms. Smith is independent in all self care activities, with the exception of transfer assist to the padded bath bench.

Cognitive/Communication: Ms. Smith is functional in cognitive-communicative areas.

Social/Emotional: Ms. Smith presents with appropriate social emotional adjustment to her present situation. She is looking forward to discharge home with her parents.

Discharge/Community Re-entry/Follow-up Appointments: It is planned that Ms. Smith will discharge to her parents' home. Her date of discharge is now set at 9-18-96. She completed a successful therapeutic home community visit over the weekend. She will work with therapy in the areas of accessibility, stairs, and discharge planning for mobility and safety. Her equipment needs include a padded bath bench, rental manual wheelchair, cushion, and front wheel walker. Outpatient physical therapy 5x per week is recommended upon her discharge. She is planning to obtain physical therapy services at Green Meadows outpatient facility with Jason Kemper, P.T. She will have a home physical therapy program in addition. Occupational therapy will devise a written home program at discharge.

Patient/Family Education: Ms. Smith and her family have been active in the educational process. Continued education will be provided based on her ongoing needs.

Interdisciplinary Protocols: Ms. Smith is currently on the Fall Prevention I Protocol.