Soap Note Research Paper

Introduction

The patient is a 45 years old male who presents lethargic laying supine.  He was admitted to the hospital 7 days ago based on a motor vehicle accident and come out of a comma today morning. For the last few days, he was being evaluated for any back pain. The patient performed bed mobility for at least three days with complete assistance.  He felt a mild pain that went down to his left knee with some degree of feet numbness and exhaustion. While he lies  with his  back directly the pain seems to  increase  a bit  but he has  no  issues related to urination,  chills fever,  diarrhea, nausea or even  abdominal  aches.

The patient has acquired two distinct brain concussions as well as a skull fracture on his temporal left bone. He is additionally on DX with an inclusion of an incomplete SCI paraplegia at the T1 level.  He has in the past be diagnosed and treated for chronic bronchitis and allergic asthma.  In the past, he was also a smoker which contributed to the chronic bronchitis and asthma. He is characterized by Aphasia since he lost the ability to express or even understand speech which was caused by the occurrence of brain damage.  He agreed to engage in a mumbling physical therapy to increase his mobility and physical flexibility since he is Aphasia.

He has  a weak  cervical  posture which is  on both  the  extension  and  flexion  while not on the neck brace. For the TF  he is assisted  by  at least  to persons  since his mobility  is challenged and for  the postural  spine,  changes  are conducted after  every two  hours.  His left eye has a bruise.  He was  able  to  adjust and follow  the  PTA’s finger  in a lateral movement  averagely using  the left eye but the right  eye sight  has decreased and  he often  losses  track while  attempting to utilize it.  His  chest  expansion  is one that  is  limited  because he  is characterized  by  shallow breathing  and his tone has a declarative posture. This demonstrates some risks of DVT which can be managed (Malone & Lindsay, 2006).

The patient is a retired fireman who lives in his colonial home with his wife.  Their house  is characterized  by  the  lack of  hand  railing  features  and  its  construction limits  wheelchair  ramps  and the  only  ramp  that  he can use  is one that  is located in the  garage that leads  to the house. This challenges him with mobility within the house and outside.  His family was inclusively advised to join emotional assistance to the patient and offer their participation during his hospitalization and after discharge.  Information was offered to the family in regard to TBI management program and SCI supportive group. The patient was assessed with the utilization of different techniques.  First, the coordination technique was utilized to point at the different directions using the finger which helped to examine the ability of both of his eyes. AAROMUE stretching was conducted for 10 stretches three times every day (10*3) as well as PROM to LE. This is a primary way of decreasing pooling of blood and reducing the probability of getting Edema (LeMura, 2004).  Also, PNF EU with rhythmic initiation and LE PROM technique was additionally utilized.  For the patient’s intervention,  he completed  TRX for a double period  based on his  low  capability  to performance  and the reduced  mental and  speaking  challenges.  He  is  additionally  incapable of participating  in most activities  his  mental  status  has  been established  to be decreasing.

The patient demonstrates the presence of acute distress despite the fact that he is characterized by shallow breathing and mental status diminishing. He does not have any swelling or deformity but he lacks comfort due to the reduced movement abilities.  He  will be discharged in four days time  to the  IP unit Mm. AAROM with the  tolerance of the  breathing  as well as the bed  mobility  exercises in the first  day  after the transfer.  In the second day  the ability  to  make additional  postural changes along the  cervical  section  and MMT for the  elbow flexibility  for four  or five times a day. The patient needs active EU stretching, Tot A and log for each activity and also for trunk. Bed mobility posture while sitting and stretching with an equal sitting balance for at least 5 minutes is necessary. The patient gives almost zero effort while performing any of the exercise activities and stares at a single place blankly.  He requires tactile and speech clues at all the communication levels and exercising activities. In the INP rehabilitation plan, the patient has wheel chair training.

The patient is expected to follow-up with the specialist who made the diagnosis and is taking his through the transition period.  DVT prophylaxis is the basic that will be targeted mainly on predisposing triad factors such as hypercoagulability, trauma and Venus stasis (Lescher, 2011).  The  patient  is highly  encouraged  by nurses to  get engaged  in bed  mobilization  based on his limited abilities  as well as  leg exercises with total  assistance  his  he is at  risk  of DVT and this activities  are  useful in  activating  his calf  pump muscle.  In addition breathing exercises are encourages in order to help the returning of venous (Lescher, 2011). Since he has  a shallow  breathing  this shows that  he has some  breathing issues  which  can be  managed by the  utilization  of therapy. The patient is prescribed for a full bed rest for some days to manage his respiration. However, ambulation can be adopted sooner which is useful for atelectatic ventilation around the lung environment. 

Bed mobility and repositioning  are recommended  to  increase his general  ability  to  coordinate  all the body sections which will additionally  benefit his breathing  system.  Breathing exercises will be consistent since his respiratory is characterized with breathing issues that needs proper management (Malone & Lindsay, 2006).  His sitting balance will additionally increase with breathing and trunk stabilization.   With stability, the patient will be transferred from the wheel chair to utilizing sliding board that will stable his sitting ability.  In addition,  this will  increase his ability to  move around  the  surrounding  at  ease  even after discharge given that  his  house  lacks wheel chair lamps and hands rails.  Stretching techniques and a sling looped on the thigh that will bring each leg to the opposite side for at least five times for each leg. These exercises are targeted at ensuring that the EU is strengthened to offer adequate physical strength (Malone & Lindsay, 2006).

In conclusion, in order to enhance the  communication  abilities  of  the patient  motivation can be offered through  non verbal such as  using a positive  tone, touching  them as a form of encouragement and comfort  and increasing the general health care  satisfaction.  The patient’s mobility issue is fueled by the respiratory issues and aphasia and his sight on the right eye can be enhanced through exercises.  However, the ethical issue in the case is whether the patient should be pressured to show some efforts in the activities that are targeted at improving his physical and emotional wellness.  This can be achieved without pressure by enhancing communication which will, in turn, create a good relation amid the physicians and the patients.

 

 

 

 

 

 

 

            References

LeMura, L. M. (2004). Clinical exercise physiology: Application and physiological principles. Philadelphia [u.a.: Lippincott Williams & Wilkins.

Lescher, P. J. (2011). Pathology for the physical therapist assistant. Philadelphia: F.A. Davis.

Malone, D. J., & Lindsay, K. L. B. (2006). Physical therapy in acute care: A clinician's guide. Thorofare, NJ: Slack.