Occupational Therapy Progress Note

Session Activity

• Completed PADL assessment (showering and upper body dressing) and practiced functional transfers from bed to commode using a 4WW.
• Trialled long-handled sponge and sock aid to promote independence within R hip precautions.

Subjective

• Pt (Arthur Pendelton, 74M, DOB: 12/04/1950, URN: 4829104) seen on rehab ward Day 5 post R total hip arthroplasty (THA). Discussed current pain levels, adherence to posterior hip precautions, and home environment setup ahead of planned discharge.

Staff Update

• Nursing handover indicates pt required 1x min assist for overnight toileting transfers. Compliant with call bell use. Analgesia administered at 07:30 prior to morning care.

Client Update

• Expresses keenness to return home to his wife by the end of the week, though feels anxious about managing the two front entrance steps.
• Reports stiffness and localised ache in the R lateral hip and gluteal region, requesting review of seating height.
• R hip ache present since surgery, worse in the mornings; rated 4/10 on VAS during movement, 1/10 at rest.
• Aggravated by prolonged sitting (> 30 mins) and transitional movements. Relieved by paracetamol (Panadol®) 1,000 mg PO QID, oxycodone (Endone®) 5 mg PO PRN, and repositioning with a wedge cushion.
• Pain has steadily decreased from 7/10 on Day 1 post-op; functional mobility and weight-bearing confidence are improving daily.
• Underwent L THA in 2019; managed via 2-week inpatient rehab followed by outpatient physiotherapy, achieving full return to independent baseline.
• Currently unable to bend to reach lower limbs for washing/dressing due to 90-degree hip flexion precaution; unable to drive or complete heavy domestic IADLs.
• Mild R lower limb pitting oedema; denies calf tenderness, paraesthesia, dizziness, or SOB.

Objective

• BP 128/78 mmHg, HR 72 bpm, SpO2 98 % on RA, Temp 36.7 °C (measured at 08:30).
• Sit-to-stand requires mod verbal cueing to avoid R hip internal rotation and flexion > 90 degrees. Mobilising 25 m to bathroom with 4WW, WBAT, supervision only. Independent with upper body washing/dressing seated on perching stool; requires min assist for lower body tasks even with adaptive equipment.
• Alert and oriented x3 (person, place, time). Cooperative, pleasant affect, good insight into surgical precautions and falls risk.
• Hb 108 g/L (15/05/2024). Post-op Pelvis X-ray (13/05/2024): satisfactory alignment of R THA prosthesis, no periprosthetic fracture.

Assessment

• Reduced functional independence in PADLs and transfers secondary to acute post-op pain and posterior hip precautions following R THA.
• Post-operative deconditioning.
• Uncomplicated post-op recovery trajectory following R THA.

Plan

• Continue daily OT input focusing on lower body dressing mastery with assistive devices and kitchen IADL assessment tomorrow.
• Reinforced posterior hip precautions (no flexion > 90 degrees, no adduction past midline, no internal rotation) and energy conservation techniques during ADLs.
• Liaise with ward Physiotherapist regarding step practice prior to discharge.
• Repeat FBC and U&Es scheduled for 18/05/2024.
• Prescribe and order over-toilet frame (OTF), long-handled reacher, sock aid, and high-back chair for home delivery.
• Family conference scheduled for 17/05/2024 at 14:00 to confirm equipment heights and discharge transport with pt's wife.

Any Actions

Send home furniture measurement form to pt's wife via email today to confirm bed and lounge chair heights.