Click-to-copy neuro re-ed documentation for PTs and PTAs in skilled nursing. Free, no login.
Patient was placed in seated position without support; give dynamic tasks to increased strengthen of core and self righting reaction.
Patient was progressed through coordination and motor task for right LE in seated to improve volitional movement and coordination with functional mobility.
In order to improve dynamic postural control and improve safety during ambulation, patient was coached through balance and coordination exercises to improve hip and ankle strategies and proprioception input. Exercises included standing on parallel bars without BUE support with feet apart, feet together, tandem stance, and over foam surface with eyes open and eyes closed and stepping exercises via side-stepping and braiding. Patient required moderate visual and verbal cueing for increased step length and safe performance of exercises.
In order to increase participation to ADLs patient was progressed through sitting tolerance task for improved static postural control, trunk strength, righting/protective strategies, and tactile input to feet for improved proprioception. Patient required mod A for supine to/from sit transfers and maximal verbal and tactile facilitation to trunk and BUE in order to maintain sitting balance. FIST administered with resulting score = 13/56. Patient was able to tolerate sitting without back support for 4 minutes and sitting with back support for 20 minutes.
Patient was coached through stand-pivot transfers WC to/from mat in order to increase tolerance to sitting position without back support. Emphasis of treatment was to improve static postural control, trunk strength, and righting/protective reactions in sitting position for improved bed mobility and participation in ADLs. Patient required maximal verbal/tactile/visual facilitation in order to correct and maintain proper anatomical alignment. FIST performed with results 18/56.
Patient was progressed through sitting tolerance at edge of mat in order to assess and improve static and dynamic balance, proprioception, and righting reactions with improved upright posture. Activities in sitting with/without use of BUE included sitting eyes open/closed, reaching of objects in all directions, scooting forward/backwards/sideways, picking up objects from floor, accepting perturbations in all directions, and marching. Patient required RUE support in order to maintain balance and moderate verbal cueing for correct and safe performance of exercises.
In order to increase participation in ADLs with dressing, hygiene, grooming and feeding, patient was coached through bed exercises with min A via rolling to L/R using siderails and supine to/from sit for improved sequencing and independence of tasks. Patient was progressed through sitting tolerance at edge of mat in order to assess and improve static and dynamic balance via sitting with/without use of BUE, acceptance of perturbations, sitting with eyes open/closed, reaching of objects in all directions, scooting forward/backwards/sideways, reaching to floor for objects and marching. Additional goals for tx were to increase righting and anticipatory reactions, BLE strength, coordination, postural awareness, and functional activity tolerance. Patient required moderate verbal/tactile facilitation in order to initiate tasks and perform tasks correctly.
Patient was coached through stand-pivot transfers WC to/from mat in order to increase tolerance to sitting position without back support. Tasks in sitting included eyes open/closed, stabilizing self with perturbations, lifting feet, reaching, and scooting. Emphasis of treatment was to improve static postural control, trunk strength, and righting/protective reactions in sitting position for improved bed mobility and participation in ADLs. Patient required maximal verbal/tactile/visual facilitation for correct and safe performance of tasks. FIST performed with results 27/56.
Patient was facilitated in sitting at edge of bed with BUE in order to improve static/dynamic balance, righting/protective/anticipatory reactions, trunk control/stability, and postural awareness. Patient was able to maintain sitting position without back support and accept manual perturbations to upper trunk in all directions x 10 minutes. Patient required maximal verbal/visual/tactile facilitation for improved upright posture and proper placing of BUE and BLE.
Patient was facilitated through static/dynamic activities in sitting without back support in order to improve static/dynamic postural control, upright posture, proprioception, righting/protective/anticipatory reactions and trunk control/stabilization for improved independence during sitting ADLs. Patient required maximal facilitation via visuals with demonstration and use of mirror and tactile cues for improved techniques.
In order to improve tolerance to functional activities in sitting, patient was facilitated during sitting at edge of bed with use of LUE for improved proprioception, righting/protective reactions, static dynamic postural control, and trunk stabilization. Patient required maximal tactile/visual/verbal cueing in order to improve techniques to regain balance and obtain proper anatomical alignment. Patient demonstrates tendency to list and lose balance to more involved R side; therefore, step was placed under RLE to encourage increased use of R UE and LE to maintain balance.
Patient was progressed through PROM and stretching exercises to BLE in all planes with emphasis on increasing B knee ext ROM and R hip IR ROM for improved anatomical alignment and joint health. Effective handling techniques were identified for the development RNP and contracture management program as follows: calming, on-going verbal instructions and sustained pressure to antagonist musculature. Patient was lead through B knee ext/flex AAROM and repositioning in supine for improved self-repositioning and redistribution of pressure points in order to protect skin integrity.
Pt was provided repositioning strategies in supine position to B LE to improve positioning to reduce risk for contracture and improve reciprocal weight shifting strategies.
Pt participated in static sitting activities in w/c required verbal and tactile cues for proper upright position in preparation for standing activities with correct postural mechanics.
Pt coached in static standing activities 3 sets 30 secs requiring verbal and tactile cues on proper upright posture when standing to maintain balance during standing activities.
Pt was instructed on dynamic sitting activities with lateral weight shifts with cues to perform lateral weight shifting strategies necessary to improve functional mobility in EOB activities.
Pt was instructed on dynamic standing activities in // bars with lateral weight shifts to improve stability and safety in order to safely perform gait activities.
Pt was instructed on dynamic standing activities while crossing midline to improve safety with balance during mobility tasks. Verbal cues were given to facilitate proper trunk rotation with dynamic activity.
Pt was instructed on dynamic standing activities 3 sets x 30 secs requiring tactile cues on proper lateral weight shifts in order to maintain proper balance to facilitate proper foot placement with functional transfers.
Applied BLE hip, knee and ankle approximation techniques to stimulate joint mechanoreceptors and increase LE proprioception for proper positioning and minimized negative effects from immobility and WB.
BLE position for anatomical alignment and application of joint approximation techniques to increase joint awareness and reduce negative effects from active mobility. Pt continues with L side neglect and apraxia limiting mobility and participation to position limbs for transfer and all ADLs.
Patient received bed mobility rolling training at MOD A, and gross motor muscle facilitation for functional transfers in sit to stands at MAX A inside // bars. Patient also performed PNF core trunk muscles techniques for static sitting balance in w/c requiring MAX A support at poor+ trunk balance with increased posterior trunk lean.
Pt was led through PNF techniques applied by therapist through B LE joints w/ emphasis placed on L LE to increase standing tolerance to enhance stand pivot transfers. Approximation technique utilized to improve proprioception, followed by sit to stands performed w/ extra time required and proper nose over toes technique emphasized in // bars. Pt was able to stand x 2 and complete stand pivot transfer w/ CNA from w/c<>bed w. Min A required and extra time for increased safety.
Manual joint approximation techniques and use of rymthic occiliateion to increase joint proprioception and reduce negative effects from lack of use.
Pt. was instruced on dynamic sitting activites with lateral weight shifts with cues to perform lateral weight shifting stratigies necessary to improve functional mobility in EOB activites.
Pt. was instruced on dynamic standing activites in // bars with lateral weight shifts to improve stability and safety in order to perform safely perfome gait activites.
Pt. performed stepper needing proper cues in preparation to improve recripical pattern necessary to improve distance in 6 min walk test to 150 meters with safety.
Patient performed dynamic standing balance on Airex foam pad x --- min with B UE support faded to none. PT graded with multidirectional reach outside BOS; dynamic standing balance improved to ---.
Patient performed single limb stance B x --- sec x --- reps at // bars to improve stance phase stability. R LE tolerated --- sec, L LE tolerated --- sec.
Patient performed tandem stance x --- sec x --- reps with UE support faded to improve narrow BOS control needed for turning.
Patient performed weight shifting anterior/posterior and lateral on dynadisc x --- min to improve ankle strategy and reduce reliance on stepping strategy.
Patient performed seated dynamic balance on therapy ball x --- min with reaching outside BOS to improve trunk control needed for EOB sitting.
Patient performed perturbation training in standing with anterior, posterior, and lateral nudges x --- reps to improve reactive postural responses.
Patient performed standing balance with eyes closed on firm surface x --- sec x --- reps to challenge somatosensory reliance given --- visual dependence.
Patient performed head turns during standing balance x --- reps to challenge vestibular contribution and simulate hallway scanning.
Patient performed step-over-obstacle training with --- inch cones x --- reps to improve anticipatory postural adjustments and clearance.
Patient performed reaching outside BOS in standing at // bars x --- reps in all planes to expand limits of stability.
Patient performed Romberg and sharpened Romberg x --- sec each to assess sensory integration; patient demonstrated --- with eyes closed.
Patient performed BOSU standing balance x --- min with B UE support to challenge proprioceptive input in a controlled setting.
Patient performed sit to stand without UE support x --- reps focused on postural control rather than strength; PT cued anticipatory fwd lean.
Patient performed manual joint approximation through B LE in standing x --- reps to increase proprioceptive input and reduce postural sway.
Patient performed rhythmic stabilization at the pelvis in standing x --- reps to improve co-contraction of trunk and hip musculature.
Patient performed PNF D1 flexion B UE in standing x --- reps to facilitate trunk rotation and weight shift during gait.
Patient performed dual task balance with a cognitive task x --- min; postural sway increased, indicating limited automaticity. PT graded task down.
Patient performed lateral weight shift onto R LE x --- reps with TC at greater trochanter to improve weight acceptance during stance.
Patient performed standing on compliant surface with reach to --- height x --- reps to improve functional reach needed for closet access.
Patient performed anterior/posterior stepping strategy training x --- reps to reduce fall risk following LOB.
Patient performed core stabilization with pelvic tilts in supine x --- reps to establish proximal control preceding standing balance training.
Patient performed standing balance on wobble board x --- min with graded UE support to improve ankle strategy.
Patient performed seated righting reactions in all planes x --- reps with TC to facilitate lateral trunk flexion for EOB safety.
Patient performed clock reach in standing at // bars x --- reps to expand limits of stability in all directions.
Patient performed backward stepping x --- reps to train the posterior stepping strategy and reduce backward LOB during transfers.
Patient performed standing balance with a narrow BOS while catching a --- lb ball x --- reps to train reactive control with UE disturbance.
Patient performed proprioceptive training with vibration and joint approximation to B LE x --- min to enhance sensory awareness 2/2 neuropathy.
Patient performed gaze stabilization exercises x --- reps to improve VOR contribution to postural control during ambulation.
Patient performed Berg Balance Scale items --- to --- for skilled retraining; total score improved from --- to ---, remaining above the fall risk cutoff.
Patient performed weight shift and stepping in // bars with mirror feedback x --- min to address pusher syndrome and midline orientation.
Pt was provided with step-ups in preparation for DC. Pt was also provided with toe-touches using 4-inch and 5-inch cones to promote SLS, unilateral WB, and ankle strategies for balance x 10 reps x 3 sets