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Etta Rose (Problem List (Past Medical Hx (Asthma, Bronchitis, Wheezing,…
Etta Rose
Problem List
Past Medical Hx
Asthma, Bronchitis, Wheezing, Cough, Shortness of Breath, Hx of smoking 1-2 ppd
Vitals
Hypertension (BP:168/70), Sinus Tachycardia (HR: 110), Edema- Bilateral 1+, Generalized weakness
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Psychosocial
Depression: Recent loss of Husband, Decline in physical health
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Assessments
MOHOST
This assessment would be use the Model of Human Occupation to guide treatment for Etta - assessing her volition, habituation, skills, and environment. We can gain an overview of the client's occupational functioning from this assessment.
Mini Mental State Exam
This assessment will be used to examine Etta's current cognitive function because she reported feeling "confused". The assessment will include tests of orientation, attention, and memory.
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STG's
Within 2 weeks, Etta will create a daily calendar for drinking, eating, and medication times, requiring moderate assistance, to reduce risk of aspiration.
Within 2 weeks, Etta will create a list of 10 ingredients, Mod I, in preparation for completion of a 3-step meal.
Within 2 weeks, Etta will independently identify 3 foods that cause her to cough/choke, and replace them with alternate food options, in preparation for reduced risk of aspiration when swallowing/eating.
Within 3 weeks, Etta will identify and utilize eating posture for reduction of aspiration, with 1 verbal cue, in preparation for self-feeding, evidenced by no signs and symptoms of aspiration.
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LTG's
LTG 1: Within 6 weeks, Etta will prepare 3-step meal within 30 minutes, Mod I, in preparation for independence in meal preparation and nutrition management.
Energy conservation techniques in the kitchen (preparing enough food for more than one meal, location of cooking supplies in kitchen)
Meal preparation (consider high energy foods that will give substantial nutrients throughout the day, focus on snacks that are healthy and easy to prepare - ex: almonds)
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Create a breakfast, lunch, and dinner meal plan routine for Etta. The plan will include location of meal, length of mealtime, and surrounding stimuli.
grade up: included additional steps in meal prep - have her gather supplies from different parts of the kitchen
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LTG 2: Within 6 weeks, Etta will utilize strategies to minimize aspiration of food and liquids, with moderate assistance, in preparation for self-feeding.
Practice eating strategies with therapist (slower swallows, smaller bites, etc.)
Educate client on what kinds of foods to eat, what textures are better, and how to prepare those.
Collaborating with Etta to explore new food options (smoothies, pureed foods, etc.)
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