Ten days after his operation, Mr. Ames was admitted to the rehabilitation unit with the following orders:
Two days following his admission to the rehabilitation unit the IGA team meets to develop his treatment plan for the rehabilitation center. Nursing, OT, PT, and psychological services have made their initial evaluations, and the social worker has visited with him and his wife. During the team meeting each service provides: (1) a summary of their evaluation findings and (2) a plan for treatment.
Print the IGA form (pdf). During the meeting act as the team leader and fill in the form to develop the action plan for the virtual team for Mr. Ames' time at the rehabilitation center.
Mr. Ames' nurse reported on wound management, foot inspection training, medications, nutrition, and summarized the podiatrist's consult and recommendations. Reportedly the patient had onychomycosis (fungus) with mild perionychia toes 4 & 5. A small, grade 1 subungual (unguis = nail) abscess noted on the medial aspect of the great toe. Nails were trimmed and ulcer was cleaned with sterile saline and dressed. Recommendations: fit for pressure-relief shoe, continue regular dressing change for left great toe.
While in bed, Mr. Ames tends to want to prop the right leg on pillows to maximize comfort and must be reminded to remove the pillows.
|ADL||Requires moderate assistance in lower body dressing, bathing, toileting
Fatigues after 10 minutes of light hygiene and dressing activity and he requires a rest period
Decreased function due to trunk instability and poor balance
|IADL||Limited reach due to instability impairs functional tasks outside arm reach|
|Prehension||Grasp strength on dynamometer
52# in R hand
45# in L hand
|Sensation||Touch/pressure threshold evaluated using Semmes-Weinstein monofilaments with score of 4.31
Diminished protective sensation in both hands
|Vision||Reduced acuity requiring larger font (16-18 point) for reading|
Occupational therapy will be concerned with Mr. Ames' ability to care for himself independently in the home setting. His problems are compounded by deficits from his diabetes. His neuropathy, decreased sensation, and low vision affect activities involving grasp and release, and present safety issues in simple meal preparation and bathing. A priority will be to work on increasing his endurance through energy conservation and the use of assistive devices which will increase his ability to perform his ADLs and IADLs.
As Mr. Ames will be staying at home alone while his wife is at work. It will be important to identify his daily routine and focus on those tasks he will need to perform independently. Therapy will include activities to increase manual dexterity and balance during functional tasks.
To achieve independence in dressing, bathing, and toileting the following adaptive equipment will be issued to Mr. Ames: transfer tub bench , 3-in-1 commode, reacher, and long-handle dressing devices. He reports that he has grab bars installed in the tub and toilet areas at home. The installation should be evaluated during a home visit for safety. A hand-held shower has also been recommended to Mr. Ames.
Energy conservation and safety techniques will be incorporated into his functional training. His comprehension of safety and his ability to adjust to his decreased sensation and balance will be evaluated in tasks such as simple meal preparation and bathing. His lower extremity dressing training will include diabetic foot care instruction, i.e. visual inspection for pressure points, wrinkles in socks, dryness of skin. He is at risk for falls.
Physical therapy will address Mr. Ames' mobility, preparing him to use the artificial limb that will probably be fitted in the future. Upon examination, the right residual limb (stump) operated site was dry; the skin color was blotchy.
His left lower extremity skin was intact except for the small lesion on the great toe. His range of motion (ROM) and strength are within functional limits for the upper extremities and trunk, with mild impairment of strength in grip bilaterally. He has good static sitting balance. His lower extremity strength was 4/5 for most key muscle groups. ROM of the hips, knees, and left ankle were less than normal, but functional, and should stretch out with positioning and some effort on his part. He needs full right hip and knee ROM to allow good fit and use of the prosthesis.
Mr. Ames requires SBA (Stand By Assist) for transfers and standing for gait because of orthostatic hypotension when he gets up. He complains of lightheadedness. He needs verbal cues to pump his left ankle and take a few deep breaths before standing. He requires contact assistance of one person with a roller walker. His endurance is low as he can walk no more than about 10 feet without some shortness of breath. We need to obtain a good shoe for the left foot before he is encouraged to walk much farther. Since he sleeps with the head of the bed elevated to assist with breathing, he needs to try to lie prone (on his stomach) for several minutes each day to stretch his hips.
The physical therapists will work with Mr. Ames on transfers and gait with an assistive device, using a roller walker because it requires less energy than a pick-up walker or crutches. Crutches would be preferred because they may encourage a more normal gait prior to walking with the prosthesis.
Mr. Ames will learn range of motion exercise for the right residual and left lower extremities plus strengthening exercises for the quadriceps, left ankle dorsiflexors, triceps and other muscle groups as needed. His strengthening exercises should be made as functional as possible, for example, by strengthening the left quadriceps and triceps by lowering himself slowly into a chair. PT will work with the nursing staff to teach stump wrapping and reinforce correct bed positioning.
MSW met with Mr. and Mrs. Ames to discuss discharge plans. Both Mr. and Mrs. Ames stated plans for Mr. Ames to return to live at home and expressed concern regarding options for assistance at home if Mr. Ames is not fully independent when he leaves the rehabilitation center. MSW provided the Ames with the names of a local home health agency that can provide services for Mr. Ames in his rural home. Mrs. Ames expressed relief that support services would be available.
Mr. Ames expressed the desire to not add to his “wife's burden” when he returns home. Mrs. Ames expressed the desire to protect her own health as she didn't realize how exhausted she had become just prior to Mr. Ames' hospitalization. Mrs. Ames requested assistance with contacting all support services available in her area as she realizes she can no longer “do this alone.”
MSW will maintain contact with Mr. and Mrs. Ames and will initiate referrals to home health and support services prior to discharge.
Mr. Ames reported experiencing mild distress regarding the amputation of his lower leg, although he remains comfortable with his decision to follow this course of treatment. He acknowledged distress regarding his decline in physical functioning in recent years and his increasing need to depend on others for assistance, particularly since the amputation. He also expressed concern regarding the impact his medical problems are having on his wife. A brief mental status screening (Mini-Mental Status Exam) was conducted, and Mr. Ames performed within normal limits.
Mr. Ames' mood will be monitored, and psychological services will help him cope with his physical limitations. Some issues that may need to be addressed include changes in his self-image secondary to his physical limitations and coping with discomfort regarding the need to rely on others for aid.
Although Mr. Ames performed within normal limits on mental status screening, given his medical history, which includes several risk factors for cognitive decline (e.g., diabetes, coronary artery disease), his cognitive functioning will still be monitored. If he appears to be having difficulties learning and participating in rehabilitation, neuropsychological testing may be indicated.
Psychology services will also be offered to Mrs. Ames, to assess her coping with her husband's medical difficulties and to address issues she may be experiencing as a result.
Conclusion of Team Meeting
By the end of the meeting, the IGA team will have decided what, if any, other services are indicated for this patient while he is at the rehabilitation center, and request referrals as needed.
When you have completed the IGA form including the plan of action, compare your IGA form to the one developed by our team (pdf).