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Guillain Barré

Progress Notes

July 22, 1996

Barksdale, Denise
12-34-56-78

Case conference No: 1
Date: 7-22-96
Adm. Date: 7-15-96
Case Mgr: Braddock
Critical Path: NPF Changed to: ____ on _____
Next C/C: 8-5-96
Funding Source: Primary Gencare, UMC HMO Secondary
Admission Level: II Changed to ___ on ___
Discharge destination: Home with parents
Estimated Date of Discharge: 10-10-96
Patient Status for Week of 7-18-96

Health Status: Ms. Barksdale is a 37 yo 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 initially treated and released from the hospital for hepatitis then readmitted.

She progressed to respiratory failure by 5-30-96 and weaned by 7-13-96. She required a tracheostomy on 6-12-96. She was transferred to the general care floor by 7-15-96 and transferred to Rusk on 7-18-96 following with continued motor deficits and paresthesias. Ms. Barksdale's tracheostomy remains in place with respiratory treatment. X-rays will be completed on this date to evaluate for the possibility of lung infiltrates. She is eating well and is scheduled to see a dietitian regarding weight management. She has a Foley catheter in place and is constipated at this time.

Physical: Ms. Barksdale remains lethargic with poor endurance in physical evaluations. She continues to exhibit no motor return in her lower extremities and is dependent in transfers with a 5 person lift. She remains dependent in bed mobility. Ms. Barksdale is experiencing motor return in her upper extremities with intrinsic minor hands. She requires moderate assistance for light hygiene and is dependent in lower body dressing. Sensory evaluation is pending upon patient's ability to attend and participate in the evaluative process.

Cognitive/Communication: Ms. Barksdale is functional in cognitive-communicative areas. Her speech intelligibility is high. Neuropsychology evaluation is pending.

Social/Emotional: Ms. Barksdale's parents are supportive and the family is optimistic regarding her recovery. She will be followed by psychology to evaluate adjustment issues.

Discharge/Community Re-entry/Follow-up Appointments: Ms. Barksdale would like to discharge home with her parents and plans a trip to Reno in October. Her estimated date of discharge from Rusk Rehabilitation Center is 10-10-96. The equipment needs upon discharge include: folding walker, manual wheelchair (rental), cushion for relief of pressure, sores, possibly a bedside commode, bath bench. Her obesity is problematic and she may require special ordered equipment due to her size.

Patient/Family education: Ms. Barksdale and her family have been active in the educational process.

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