| | |
| 20/05/present date | Medical admission: |
| 1100hrs | 55 year old male |
| | Presents with painful R foot ulcer |
| | PMH: Colorectal Ca |
| | Dx 4 weeks |
| | Yet to commence treatment |
| | T2DM |
| | Dx 4 weeks ago |
| | Metformin monotherapy |
| | HbA1c 7-8% |
| | Peripheral Neuropathy |
| | ? Related to T2DM. No cause noted |
| | HTN |
| | Presenting complaint |
| | 3/7 worsening pain and swlling R foot |
| | Known wound on plantar aspect of foot, unsure of progress |
| | No systemic symptoms of fevers, chills, nausea |
| | MEDS: metformin 500mg twice daily |
| | Ramipril 2.5mg |
| | All: NKDA |
| | O/E: BP 145/80 HR: 75 regular RR: 20 SATS: 98% RA |
| | Heart sounds normal |
| | Absent sensation to monofilament on plantar aspect of feet bilaterally. No motor deficits. |
| | Neurological exam otherwise NAD. |
| | Wound: R plantar aspect- 2 x 2 cms punched out ulcer under 1st MTP. No Pus. |
| | Surrounding cellulitis |
| | Issues: Neuropathic ulcer R foot |
| | Neuropathy out of keeping with early T2DM |
| | Plan: Add empagliflozin for diabetic control |
| | Commence IV augmentin for infection |
| | Podiatry R/V |
| | Neurologist review re: peripheral neuropathy |
| | Urine ACR- evaluate for diabetic nephropathy |
| | A/H team review and discharge planning |
| | ————————————————————————-C. Johns #2323—————————- |
| 20/05/present date | Nursing: New patient admitted to ward, Bed 06 at 0945hrs. Mr Davies presents with a right |
| 1130hrs | foot, stage 4 pressure area around head of 1st metatarsal (plantar). Wound management |
| | plan completed. Mepilex dressing in place over wound. Daily dressing changes noted. |
| | History of obesity (160kg) , diagnosis of bowel cancer and T2DM 4/52 ago, Peripheral |
| | neuropathy, Hypertension. Nil known allergies. Justin scheduled to commence daily |
| | pre-surgical radiation therapy in 2/52 as an outpatient in the Radiation Oncolgy Unit. Will |
| | receive concurrent chemotherapy via continuous infusion pump over the course of his |
| | radiation therapy. Message left with oncolgy re: Mx plan due to current inpatient status. |
| | BP:145/80mmHg. HR: 75bpm. RR: 20bpm. O2 sats 98% RA (Room air) |
| | Neuro: Presents as alert and orientated ? Withdrawn *** Complaints of tinging in lower |
| | limbs during full hoist transfer onto bed. Sides up, call bell in reach. Falls risk assessment |
| | completed. Lower limbs warm to touch. Right lower limb noted to be hot, swollen and red. |
| | Respiration: Respiratoy assessment NAD. Gastro: NAD. IV cannula in situ (dorsum R hand) |
| | Patient states nil issues with eating once set up on ward. Full assistance with bowel |
| | Management. Pressure area Risk Assessment updated. Psychosocial: Separated, lives alone |
| | Next of kin (NOK) notified of transfer to ward. Equipment: urinal at bedside. |
| | For AH review, wound management, discharge planning—————-S.Thomas (RN) |
| 20/05/present date | Occupational therapy: Initial contact and assessment with Mr Davies who was admitted |
| 1150hrs | with stage 4 pressure area on plantar aspect of right foot (1st MTP). Diagnosed with bowel |
| | cancer and T2DM 4/52. Sitting up in electric hospital bed on OT arrival. Introduced role of |
| | Occupational Therapy. For full details of assessment refer initial assessment form in |
| | medical record. Mr Davies describes his mood as ‘worried’ and ‘low’ and that he has been |
| | having difficulties managing his health and medical conditions prior to admission. Justin |
| | states that his life has changed considerably in the last 4/52. He feels he has gained weight |
| | and lost all motivation to exercise. |
| | Current Occupational Performance Summary: |
| | – Justin currently a full hoist transfer on ward due to NWB status in R) foot 2nd to wound |
| | – Set up assistance required with eating in bed using bed tray |
| | – Set up assistance with grooming in bed. Nursing staff placing all items within reach (bowl, |
| | hair brush, tooth brush, etc) |
| | – Max assist with hoist transfer from bed to wheeled commode for bathing. Once setup, |
| | independent upper body (UB), Max A with lower body (LB). Significant SOB ++. |
| | – Currently only wearing hospital gown, Mod A x 1 to don it when lying in bed. |
| | Occupational Performance Plan |
| | – Due to Justin’s current weight of 160kg, Justin requires full hoist transfer on ward from |
| | bed to bariatric wheeled commode, HBC and MWC. 2 x staff to push in MWC. Awaiting permission |
| | – Awaiting go ahead from PT and medical team to trial Justin with a bariatric wheeled |
| | zimmer frame during transfers. Will complete joint assessment with PT once approved. |
| | – Requires medical follow up and plans |
| | – Will commence self care review 1/7 |
| | ——————————————— H. Joans (Harriet Joans, Occupational Therapist) #4987— |
| 20/05/present date | Physiotherapy: Initial mobility review with Mr Davies, admitted to ward with R) foot ulcer. |
| 1300hrs | Currently NWB in R) foot. Dressing in situ. Consent gained. |
| | Current transfers and mobility status on ward: |
| | T/F: full hoist (XL sling size) on ward from bed to HBC/Wheeled commode/MWC/Bed |
| | Mobility: MWC on ward only with 2 x staff pushing |
| | Bed mobility: Slide sheets x 2 for repositioning as appropriate otherwise full hoist |
| | Standing balance: Not assessed due to NWB status |
| | Sitting balance: Nil issues noted SOEOB or in HBC or MWC |
| | Plan: full mobility and transfer review once medical permission to trial a bariatric wheeled |
| | zimmer frame granted. Will F/up 1/7 with medical team |
| | – Liaise with occupational therapy re: bariatric electric wheelchair to facilitate access to gym |
| | ————————————S Richards Sam Richard, PT #9898———————————— |
