Homer Xiang, Sr. 82 yo M

Problems/Strengths

Problems

Strengths

Occupational Performance Deficits

Assessments

Client Priorities

Interventions

Goals

STGs

LTGs

In 30 days, client will sit up right for a 15 mins of the feeding/digesting time via PEG, with less than 2 rest breaks, while the other 45 mins, client reclined with back support form bed.

In 30 days, client will swallow a bolus of pudding, with use of NMES and chin tuck.

In 60 days, client will sit up right for 30 mins of the feeding/digesting time via PEG by himself, with 0 rest breaks, while the other 30 mins, client reclined with back support from the bed.

In 60 days, client will swallow a bolus of pudding with less than 2 verbal cues on technique to swallow properly.

Observations

FIM

COPM

BEDQ

  1. Caregiver education on infection control/prevention. Teaching his wife the signs of infection as well as the proper way to clean the insertion site, by cleaning once a day with tap water and making sure it is fully dried.
  1. Caregiver education on the use/need/complications/procedures for the use of the PEG to ensure proper care when discharged into home for home health care. It is important that the caregiver can identify how the machine is used as well as precautions and complications that could arise while using the PEG.
  1. Working on proper body positioning to ensure safety when feeding through the PEG tube. Patients body should be sitting upright during and after feeding, allowing the body to digest properly and help prevent blocking or leaking will occur.
  1. Using modified swallowing techniques during feeding to help facilitate and regain swallowing function. Chin tuck and Masako techniques will be used.
  1. Caregiver education on administering supplemental nutrition and proper hydration cycle. Ultracal HN Plus at 80mL per hour along with 250mL of water bolus every 6 hours.

Up: Caregiver preforms task with no verbal cues from patient

Down: Caregiver is to set an alarm each day to remind herself to clean the insertion area

Up: Caregiver uses daily checklist of proper use/possible complications/etc of PEG to ensure proper functioning to prevent complications that can be otherwise avoided

Down: Wife has a brochure and contact number of a home health nurse that can walk her through a routine check and inspection of PEG on her husband

Up: Food won't be given until patient is an upright position to properly engage in feeding

Down: Using verbal cues before, during, and after to feeding time to ensure the patient reminds upright while feeding

Up: Having patient use the effortful swallow technique to engage and strengthen the muscles required to swallow

Up: Caregiver uses timer and reminder notes to ensure proper timing and amounts are given to her husband

Down: Uses a step by step pamphlet guiding and directing the proper amounts, times, etc of the given water and supplements

Does not drink alcohol

Patient was independent to all ADLs prior to being admitted

Patient is married, therefore has a support system

Smoked a pack of cigarettes a day for 30 years

Dependent with feeding (PEG)

Extreme weight loss after being admitted to hospital

Bed Mobility (supine to sit): Mod A

Return home to his wife's care

Patient wants to be able to enjoy wife's cooking

He wants to not feel tired all the time

Residual swallowing dysfuntion

Being able to fish in the mornings and build his model cars in the afternoon

Go to the public library once a week to pick out a new book to read

Fall risk

Lethary

Postoperative fever

Electrolyte imbalance

Hypertensio

Has no pets to care for

Patient is retired and does not have to stress about returning to work

Transfers (sit to stand): Min to Mod A of 2

Ambulation: 2 steps are attempted but not performed

Sitting (can balance for 15 mins): Min A

ADLs: Mod A

Bowel and bladder: Max A

Hydration/nutritional supplements given with semi-thick mixture

Right axillary DVT

Canadian Occupational Performance Measure will be used to better understand how the patient perceives and performs occupations. This will be used to compare throughout treatment

OT will observe client during PEG feeding, supplemental/hydration, and performance of ADLs

Functional Independence Measure will be used to score the patient in levels of performance in multiple functional areas/tasks that essential in every day life

Brief Esophageal Dysphagia Questionnaire is self reported questionnaire to determine the severity, symptom frequency, and impacts of dysphagia (Taft et al, 2016).

Down: Use of the NMES unit to help facilitate muscles to allow the patient to strengthen and use the muscles required to swallow properly