Saul Ebema

Documenting Increased Weakness

Previously patient;

• Was able to pivot
• Slept 12 of 24 hours
• Ambulated independently with walker
• Able to sit upright in chair
• Able to self-propel wheelchair
• Able to engage in 30 minutes of singing favorite songs
• Was interested in [XYZ] activities

Now patient;

• Unable to bear weight
• Sleeps 18 to 24 hours
• Ambulates with walker, but now requires assistance
• Requires lateral arm support, support with pillows, geri chair, foot rests, etc.
• Unable to self-propel in wheelchair
• Only able to listen to songs; unable to sing along
• No longer able to participate in activities

Documenting Mental Status

Is/Does the Patient:

• Able to make needs known?
• Recognize family members?
• Respond to name only?
• Wander aimlessly?
• Stare blankly or stare off into space?
• Respond to tactile/auditory stimuli?
• Combative/irritable/paranoid?
• Maintain eye contact or visually track?
• Able to smile? Flat affect? Hold head upright?
• Drool?
• Laugh inappropriately?

Documenting Mealtimes

• feed required?
• Unable to utilize silverware?
• Requires prompting/encouragement to accept food, chew, swallow?
• Exhibits prolonged chewing time/difficulty swallowing?
• Pockets food?
• Expresses no interest in food?
• Plays with/throws food?
• Takes food from others’ plates?
• Finger food only?
• How much does patient eat? Percentages are subjective, so be specific (e.g., patient consumed 2 bites of sandwich and 4 teaspoons of Jell-O). 100 percent of a piece of toast and 6 oz of tea cannot be compared to 100 percent of a steak dinner with potatoes, salad and dessert!
• Does the patient cough after eating or drinking?
• Is it taking longer to feed the patient?
• Is the patient refusing food?

Documenting Observations

Is Patient’s Speech:

• Nonsensical?
• Responds to yes/no questions only?
• Garbled?
• Inappropriate responses?
• Is speech repetitive?
• Sing-song?

Documenting Weight Loss:

• Is the patient’s weight being recorded. Is there a decline?
• Is weight loss evidenced by loose-fitting clothes, belt that is now too big, and/or extra skin folds?
• Are bony prominences evident or is patient skeletal in appearance?
• Does the patient look thinner when compared to a photo taken in healthier days?

Documenting Ambulation/Transfers:

• Requires standby, one or two person assist?
• Requires Hoyer lift?
• Does patient lean to the side in wheelchair? (This relates to FAST score 7d and indicates patient cannot maintain posture.)
• Has patient lost the strength to lift feet off the ground when transported in a wheelchair?
• Does patient need a geri chair or Broda chair?