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Ruby Jane Smith (Assessments (Bedside Log (72 hour log post admission,…
Ruby Jane Smith
Assessments
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Interview
Allows therapist to learn more about the client and her current roles and routines as well as how her occupations are affected by her GERD
ACE-R
Cognitive screen will assess her memory as well as focus and attention that are necessary to abide by GERD precautions
Dementia Questionnaire
Testing for dementia at Ruby's age will allow the therapist to accurately determine Ruby's ability to follow GERD precautions
Numerical Pain Scale
identify her current level of pain, typical level of pain, best level of pain, and worst level of pain
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Problem List
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Barium Swallow indicated granularity of mucosa, thickened folds, erosions, and stricture.
Frame of Reference
PEOP
Utilizing the unique combination of Ruby, the environment and occupation to create a client centered intervention plan.
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Goals
LTG 2: Within 4 weeks, Ruby will adhere to behavioral GERD precautions as trained, with MIN verbal cues, to increase quality of life during meals.
LTG 1: Within 4 weeks, Ruby will identify triggers and plan a weekly menu, independently, with meals that prevent GERD symptoms in preparation to participate in meal time routine.
STG 2: Within 2 weeks, Ruby will identify 3 acidic foods, independently, that exacerbate GERD symptoms, and eliminate them from her diet to improve quality of life with mealtime
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STG 1: Within 2 weeks, Ruby will identify 3 spicy foods, independently, that exacerbate GERD symptoms, and eliminate them from her diet, with therapist assistance, to improve quality of life with mealtime.
Interventions
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Intervention 3: Participate in grocery shopping with Ruby and family
Grade up: have Ruby do all the shopping independently Grade down: assist Ruby with the grocery list and making the right choices at the grocery store
Intervention1: Create and print out a daily and weekly menu and shopping list template for Ruby to utilize while planning her meals.
Intervention 4: Develop a list of foods with Ruby that trigger her GERD symptoms and find alternatives.
STG 1: Within 1 week, Ruby will adhere to behavioral GERD precautions as trained, with MAX verbal cues, to increase QOL during meals.
STG 2: Within 2 weeks, Ruby will adhere to behavioral GERD precautions as trained, with MOD verbal cues, to increase QOL during meals.
Interventions
Intervention 2: Practice proper eating positioning (if eating in bed, keep the head of the bed elevated 30 degrees or 6 inches at all times; sit upright at 90 degrees when eating/drinking. Grade up: have her demonstrate proper positioning without a visual schedule, only verbal cues Grade down: have her demonstrate proper positioning with a visual schedule, demonstration, and verbal cues
Intervention 3: Education on portion size (instead of large meals, educate her on eating small meals throughout the day).
Intervention 1: Develop an eating schedule (reflux precautions include: avoid eating within 3 hours of bedtime & remain in upright position for 1 hour after meals).
Intervention 4: Education on how certain foods improve or exacerbate symptoms affecting QOL (via visual stimuli and sorting photographs).
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Theresa Gonzalez, Gina Hernandez, Katherine McFarland, Brianna Medina