Entry 2:

Situation:
I had a patient today who is a 97yr old man, admitted into the rehab unit 2 days ago after being in an acute ward following a postural collapse. He was mobilising with a wzf but at home was using a 4ww over a distance of 30m. His goal was to go back home and to do this he needed to be able to walk I with a 4ww over the required distance. His BBS was 33/56.

Task:
The task for me has been to improve his mobility so that he is ready for discharge when all other allied health and medical goals have been met. To achieve this I needed to make sure he was safe and independent on the wzf and then progress to a 4ww, ensuring that he was safe on that with stand-by assistance initially and then independently.

Action:
Day 1 treatment included assessing his ambulation on the wzf and also aiming to improve his dynamic balance reactions. Day 2, the patient was loaned a 4ww to ambulate with on the ward and reminded of extra safety precuations involved with having 4 wheels. Since the patient is so old it is expected his balance will improve sigificantly and the fact that the reason for his admission was not related to his poor balance, the main goal prior to discharge is to return the patient to his previous functional mobility level.
Communication was also another important aspect of this intervention as when a patients mobility status on the ward is changed it must be documented in the progress notes, changed on his bedside chart and the nurses need to be made aware of the change.

Result:
The result of my intervention has meant that the patient is now ready for discharge from a physio perspective and is mobilising at the level he was prior to his hospital admission.

Evaluation:
My actions in this situation were very effective and met the desired outcome of the patient being ok for discharge in terms of mobility. Ensuring good communication with the nursing staff is also essential and I made certain all the requirements of a mobility status change were met so all staff were aware.


Strategies:
I used the strategies of goal setting, communication with patient and staff and effective assessment and planning to ensure this patient was ready for discharge as soon as possible.