Patient was a 52 year old female admitted to skilled nursing facility
following a lengthy hospitalization for acute renal failure. Other diagnoses
included diabetes, morbid obesity, severe deconditioning, and bilateral foot
ulcers. Per patient she had not walked for over a year, but her goal was to
“walk again and return home.” She would begin physical and occupational therapy
to increase her strength, endurance, range of motion, and functional mobility to
work toward her goal of returning home.
At start of care patient was unable to transfer in and out of bed, therefore
required a mechanical lift. She required moderate assistance to roll in bed and
was unable to perform supine to sit. The first month of treatment focused on
upper and lower extremity strengthening, bed and chair positioning for comfort
and pressure relief, bed mobility, and sitting balance. She refused to attempt
standing due to fear of falling. By the end of the first month, she was able to
roll in bed independently using the side rails, perform supine to sit with only
supervision, and maintain sitting at edge of bed for 10 minutes. She still
required a mechanical lift to transfer to and from the bed and chair, however
was able to tolerate sitting in chair for 3 hours 3 times a week.
After 2 months, she was ready to stand. She performed sit to stand transfer with
moderate assistance of 1-2 therapists. She was able to stand in the parallel
bars for 1.5 minutes with contact guard assist. Although she was very
enthusiastic and proud of her progress, she required much encouragement and
praise to maintain her motivation to improve. She continued to be too fearful of
falling to attempt walking. An orthotic company was consulted to make
specialized shoes for her to aid in pressure relief and prevent future ulcers
while maintaining her safety during transfers and ambulation.
After just 3 months of therapy, she was able to perform sit to stand transfer
with only contact guard assist. She was able to perform a stand pivot transfer
from bed to chair using a front-wheeled walker with minimal assist. She
ambulated with a front-wheeled walker and minimal assist of 1-2 therapists, for
20′. This was the first time she had walked in over a year, and both therapists
were her loudest cheerleaders. This gave her the courage and motivation she
needed to continue with her treatment and reach her goal.
After 5 months of therapy, she was performing bed mobility independently without
side rails and was able to transfer in and out of bed and chair with a
front-wheeled walker and supervision. She was ambulating up to 50′ with the
front-wheeled walker and contact guard assist. She could stand with the walker
for 2.5 minutes and perform minimal-moderate activities with only contact guard
assist. Discharge planning began with facility staff, therapy staff, the
patient, and the patient’s family. Due to the family living a few hours away
from the nursing home, several conference calls were made with the social
worker, therapy staff and the patient’s family to discuss equipment
recommendations and alterations/additions to the patient’s house.
The patient was discharged from therapy following 5 months of treatment but
continued to work daily with restorative nursing on ambulation, transfers, and
upper and lower body strengthening. After 4 weeks with restorative nursing, she
was performing stand pivot transfers bed to chair independently with
front-wheeled walker and walking with only supervision up to 80′. After 6 months
in the nursing home, she finally went home to live with her family.