Patient tolerated treatment for full session, demonstrating an intention to improve and progress with treatment. Patient required some rest breaks ---- with generalized low tolerance ----- but overall progressed through tasks well without complaint.
Patient continues to have deficits with strength, balance, coordination, safety and tolerance of standing tasks; which impact the patient’s ability to perform functional mobility.
ROOM Patient was returned to room and assisted back to bed; positioned properly with call button in reach. Nursing was made aware of patient positions and current status.
SEATED Patient was placed in ------ , siting in wheel chair with breaks locked --- chair alarm in placed. Nursing was made aware of patient positions and current status.
Patient is demonstrating improved tolerance to sit-to-stands and gait with as evidenced by less need for rest breaks and quicker pace in performance of activities. Oxygen saturation level at beginning and end of treatment was 95%.
Patient was alert and oriented x 1 (place, date) at beginning of session and progressed to oriented x 2 (date) at end of session. Oxygen saturation levels at beginning, during, and end of treatment were 97%, 98%, and 97%, respectively.
Patient was alert and oriented x 1 (place, date) at beginning of session and progressed to oriented x 2 (date) at end of session. Oxygen saturation levels at beginning, during, and end of treatment were 97%, 98%, and 97%, respectively.
Patient tolerated treatment well and expressed motivation to come to sitting position in next treatment.
Patient presented with a productive cough during treatment without abnormal sputum; nurse reported him having cough episodes every now and then.
Patient reported feeling very weak and debilitated today and that he has not been eating regularly due to lack of hunger. Patient refused breakfast this morning. Oxygen saturation levels at beginning and end of treatment were 97% and 98%, respectively.
Patient reported significant feelings of anxiety and demonstrated distress mid-treatment due to back pain, anxiety disorder, and PTSD. Patient was given a break to breathe and bring anxiety level down before continuing.
Patient was postioned with pillows and wedges under trunk and BLEs in order to relieve pressure points and facilitate optimal circulation.
Patient's level of cognition appears to be improving indicating improved carry-over of learned tasks.
Patient is demonstrating decreased tolerance to standing position as evidenced by increased signs of exertion with increased chest expansions and reports of minimal dizziness. Oxygen saturation levels at begining, during, and post treatment were 94%, 97%, and 95%, respectively.
Patient continues to report feelings of dizziness upon coming up to sitting and standing positions; however is demonstrating increased tolerance to upright positions.
Patient required rest breaks after each position change due to moderate symptoms of orthostatic hypotension.
Patient's BP was abnormally low at beginning of treatment (85/52 mmHg). Nurse was notified and patient was returned to bed positioned with legs elevated. Patient's BP was normalized to 120/69 mmHg within 10 minutes of lying down. Nurse reported that low BP may be due to patient being taken off peg tube feeding and progressed to bolus feeding, causing lower levels of fluid in the body. When treatment was resumed, remained within normal limits (115/66 mmHg)
Patient reported feelings of significant fullness and heavy sleepiness during treatment due to having eaten breakfast shortly prior to session. Patient requested therapy before breakfast or one hour after breakfast.
Patient tolerated tx well with no signs of distress/discomfort. Patient was cooperative throughout tx; however, impairments to cognition sometimes hinder effective therapist/pt. communication and correct performance of exercises.
Patient was cooperative and motivated to walk longer distances today. Patient tolerated tx well and did not report any distress/discomfort. VS and exertion level were closely monitored for patient safety.
Patient is demonstrating improvement as indicated by increased trunk/BLE strength, active participation during tx and increased tolerance to functional activities
Patient demonstrates potential to reach goals as indicated by good participation and improved dynamic balance.
Patient demonstrates improvement in dynamic postural control in all activities performed today. Barrier for progress is significant pain to LLE and lumbar region due to sciatica and recent laminectomy; nurse was notified and patient was advised to take pain medication 45 minutes before therapeutic treatment for decreased pain and increased tolerance to activities.
Patient demonstrates potential for improvement as indicated by ability to follow multi-step instructions and good participation during treatment.
Patient tolerated tx well as indicated by increased tolerance and participation during treatment.
Patient is demonstrating improvement as indicated by increased independence during treatment and noted carryover of learned skills outside of skilled rehab.
Patient responded to tx well as indicated by good participation and tolerane to tx.
Patient demonstrated great participation today and is showing potential for improvement as indicated by increased functional activity tolerance.
Patient is demonstrating potential for improvement as evidenced by increased FIST score to 40/56. Patient continues to require extra time for initiation and performance of tasks.
Patient demonstrates good potential to reach goals as indicated by good ability to learn new information and minimal need for redirecting and cueing.
Patient tolerated treatment well and would benefit from continued PT to improve performance and tolerance to functional activities.
Patient tolerated treatment well as indicated by improved technique, tolerance, safety, distance, and balance during ambulation.
Patient was compliant with today's treatment, and would benefit from continued PT for improved strength and endurance in order to improve upright sitting for increased participation in ADLs.