Case Studies

Case Study

Admitting Diagnosis: Chronic Obstructive Pulmonary Disease
Discharge Location: Home

A 72-year-old female who was admitted to Webster Park Rehabilitation and Healthcare Center from South Shore Hospital for chronic obstructive pulmonary disease to receive continued skilled nursing and therapy services to safely return home. Upon admission, Mrs. D. was evaluated by and participated in skilled occupational and physical therapy where she was noted to require moderate assistance for bathing and lower body dressing tasks, minimum assistance for toileting, contact guard assistance for upper body dressing and ambulating 5 feet with a rolling walker and stand by assistance to transfer. She also noted to have decreased balance and activity tolerance, increasing her risk for falling. Mrs. D. started therapy using a rolling walker and as she progressed with her therapy goals, she was able to participate in higher level functional activities to ensure her endurance and safety was maintained using a rollator. Upon discharge, Mrs. D. was able to perform all self-care tasks and transfers with modified independence and was able to ambulate 150 feet with a rolling walker and supervision. Mrs. D. made great gains towards her therapy goals and was able to return home with strong family support and home health services. Great work, Mrs. D.!

10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed


Case Study

Admitting Diagnosis: Acute and Chronic Respiratory Failure with Hypoxia
Discharge Location: Home

An 88-year-old gentleman was admitted to Webster Park Rehabilitation and Healthcare Center from South Shore Hospital for bronchitis and shortness of breath to receive continued skilled nursing and therapy services in order to safely return home. Upon admission, Mr. T. was evaluated by and participated in skilled occupational and physical therapy where he was noted to require minimum assistance for bathing and toileting tasks, setup assistance for upper body and lower body dressing tasks and supervision to transfer and ambulate 40 feet with a rolling walker on 2 liters of oxygen. He was also noted to have decreased balance and activity tolerance which increased his risk for falling. As Mr. T. progressed with his therapy goals, he was able to participate in higher level functional activities to ensure his endurance and safety was maintained using his rolling walker. Upon discharge, Mr. T. was able to perform all self-care tasks with modified independence, transfer with supervision, ambulate 125 feet on room air with a rolling walker and standby assistance and was able to navigate 9 stairs with contact guard assistance. Mr. T. made great gains towards his therapy goals and was able to return home with strong family support and VNA services. Great work, Mr. T.!

10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed


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