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ICF Case Presentation Example

Transcript: Hip Environmental Factors Participation Restrictions Assessment Activity Limitations Inadequate hip extension in terminal stance Hip flexor length Hip capsular hypomobility Inadequate hip extension in terminal stance Hip flexor length Hip capsular hypomobility Gait (insert video for movement analysis) Squat Diagnosis Classification Common Conditions Achilles Tendinopathy Subjective Exam Functional Tasks Condition 2 Motor Control Deficits Gait (insert video for movement analysis) Squat Health Condition Subjective Exam Joint Hypomobility Muscular flexibility deficits Neural mobility deficits Fascial mobility deficits Inadequate ankle dorsiflexion TCJ hypomobility Gastroc/soleus flexibility Distal Tib-Fib hypomobility Calf weakness Edema Common Features Body Function & Structure Impairments Hip Special tests Distinctive factors Inflammatory Process Initial occurrence Patient demographics DOI MOI Location of symptoms Activity Limitations SINS Severity Irritability Nature Stage Categorization Tendinitis vs Tendinosis Aggravating factors Easing factors "I have pain in the back of my ankle with walking" Personal Factors Mobility Deficits Differential Diagnosis Ankle Inadequate ankle dorsiflexion TCJ hypomobility Gastroc/soleus flexibility Distal Tib-Fib hypomobility Calf weakness Edema Treatment Timing & sequencing of muscle activation Abberant movements Condition 3 Location of symptoms Occupation / Hobbies High load to plantarflexors Ankle Occupation Social history Muscle Performance Deficits Age Gender Recreation for general health Work (walking around office) Father (3 year old daughter) Joint Hypomobility Muscular flexibility deficits Neural mobility deficits Fascial mobility deficits Functional Tasks Degenerative Process Recurrent injury Patient demographics Body Function & Structure Impairments High Copay Single parent with 2 children (4yo & 6yo)

CASE BACKGROUND

Transcript: accountant Investigators: Khalil, Grant, Yuri Bite marks were discovered at the scene. After investigating, we found that Ruby's bite marks matched those found at the crime scene. this week we learned how to match impression evidence such as bite marks, positioning, and other characteristics of teeth. Final Reporters: Hannah and Mia In conclusion we found Katie and Gregg guilty. they worked together to frame Ruby as the robber by planting her DNA and fingerprints at the scene. we think this because when we interviewed Gregg he lied four times. First, he said that he had no interaction with Katie whatsoever. This is a lie, since Joe saw them talking in Katie's shop. Gregg also said Joe was a Business Manager, and Ruby was a great worker, after trying to get her out of the company. He also said that Joe never touched the safe, which Joe also refuted. Gregg and Katie will share the insurance money from the jewels. receptionist This is the longest job she has had since she graduated college. She also has lot of medical bills to pay off because, of her ill mother. She controls the inventory of the store. Greg Sapphroni During the week we went to a fingerprinting station and we identified prints into three categories. Arches Whorls and loops. We also dusted for prints on different surfaces. This helped us solve the case in many ways because we learned how to identify and match prints. We were able to to find both Gregg and Ruby's finger prints on the store safe. But knowing that Gregg owns the store and is frequently in and out of the safe. Investigators: Bao Tran, Koley, Aaren, Andre Handwriting Evidence Conclusion Fingerprinting Analysis Sally Corundum Ruby St. Marco Investigators: Aaren, Robert, Bao Tran, Jordan ("Struggle-o") Investigators: Jaiden, Koley ,Iyonna, and Andre DNA ANALYSIS there were four suspects sally, Ruby, Gregg and joe. they read and analysized the sheets of paper with the codes, they compared it to all the other suspects handwriting. Sally and Ruby's handwriting had the most similarities to the sheets found at the crime scene. Jubilee Jewels Heist Handwriting Analysis On the morning of Friday, June 1st, Greg Sapphroni entered his jewelery store, jubilee jewels. $50,000 worth of antwerp diamonds were stolen from Greg's office. there is 4 suspects, Greg , Joe, Sally ,Ruby. Bite Mark Evidence Joe has all the paper work and other financial information about jewelery store. also spends a lot of time at the store to acquire the safe codes. Orange team CASE BACKGROUND Bite marks Analysis Our DNA team analyze the DNA left at the crime scene, based on the suspects that were listed. The labs that we did this week that helped us tremendously was the DNA testing. during that lab we learned how to match suspects DNA to the DNA found at the crime scene. Only two of the suspects DNA was found in Greg's office.Those suspects were Ruby and Joe. Joe Stone owner He has the keys and codes to the store and the safe. He could have easily pulled off an inside job without being suspected. Sales Ruby had issues with other employees. Since she began working at the store sales have declined significantly. She also has financial troubles and believes she should get better pay. Ruby has overheard about pay cuts. Fingerprint Evidence

Background Data

Transcript: Concept Map 4 Acetaminophen/1000mg/q6h/oral/for pain Bisacodyl/10mg/once a day/rectal/for constipation d/t required bedrest Enoxaparin/36mg/q12h/sub-q/to prevent clot formation d/t bilateral below the knee casts requiring bed rest Fluoxetine/30mg/nightly/oral/to treat depression Labs & Results Age: 15 Allergies: NKA Medical Diagnosis/Reason for admission: Bilateral ankle fracture d/t attempted suicide jump out of 2nd story windwo after ingesting "handful of corcidin." Reported loss of consciousness upon fall. Pertinent medical and surgical history: H/o depression, anxiety. Suicide attempt in March. Raped a few years ago-mom not aware (does not want mom to know). This will affect patient care and education because if the patient lacks good mental health, she is less likely to adhere to given instructions and more likely to continue to perform self-inflecting harm. Birth data: No data available. Erickson's Developmental Stage: Identity vs Role Confusion This is currently affecting the patient because she is trying to find where she fits in the world and displays confusion as to what her role is in this moment in time. Psychologist Erik Erikson said that this exploration is part of a psychosocial crisis, where adolescents have to find themselves otherwise if they stay in role confusion, they will feel dissatisfied and have trouble figuring out what they want out of life- which is what this patient has struggled to find. Background Data Physical Assessment Medications (Name/Dosage/Frequency/Route/Rationale) Nursing Diagnosis 1. Risk for self-harm r/t previous history of prior suicide attempt Goals: -Pt will not harm self during duration of hospital stay and upon follow-up visit -Pt will maintain connectedness in relationships for 2 weeks following discharge Interventions: -Be alert for warning signs of suicide: making statements such as, “I can’t go on,” “Nothing matters anymore,” “I wish I were dead”; becoming depressed or withdrawn; behaving recklessly; getting affairs in order and giving away valued possessions; showing a marked change in behavior, attitudes, or appearance; abusing drugs or alcohol; suffering a major loss or life change. -Question family members regarding the preparatory actions mentioned.Communicate the degree of risk to family and caregivers; assess the family and caregiving situation for ability to protect the client and to understand the client’s suicidal behavior. Provide the family and caregivers with guidelines on how to manage self-harm behaviors in the home environment.. -Before discharge from the hospital, ensure that the client’s parent has a supply of ordered medications, has a plan for outpatient follow-up, has a caregiver who understands the plan or is able and willing to follow the plan, and has the ability to access outpatient treatment. 2. Powerlessness r/t physical limitations and dependence on others to meet basic needs Goals: -Pt will demonstrate increased feelings of control over his/her situation -Pt will participate in self-care activities within physical limitations and prescribed activity restrictions Interventions- -Assess for behaviors that may indicate feelings of powerlessness (e.g. verbalization of lack of control over self-care or current situation, anger, irritability, passivity, lack of participation in self-care or care planning). -Evaluate client's perception of current situation, strengths, weaknesses, expectations, and parts of current situation that are under his/her control. Correct misinformation and inaccurate perceptions and encourage discussion of feelings about areas in which there is a perceived lack of control. -Support realistic hope about probability of future independence and ability to resume usual roles and lifestyle. -Include client in the planning of care, encourage maximum participation in the treatment plan, and allow choices whenever possible to promote a sense of control. -Encourage significant others to allow client to do as much as he/she is able so that a feeling of independence can be maintained. Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook. Maryland Heights, Mo.: Elsevier. All immunizations are up to date. Pt denied flu vaccine before discharge. From 10/25- last day they were recorded -RBC: 3.42 (4.1-5.3)/ Low d/t recent bilateral ankle surgery and current Lovenox medication -Hematocrit: 27.7% (35-45)/ Low d/t recent bilateral ankle surgery and current Lovenox medication -Hemoglobin: 9.0 (12-15)/ Low d/t recent bilateral ankle surgery and current Lovenox medication -Platelets: 598 (150-450)/ High d/t inability to excercise as a result of bilateral below the knee casts requiring bed rest Social Work Services: Mom wanted to be called by a social worker because she had questions regarding discharge since she will not make it before then. -Pulse: 89 bpm/ 2+(Normal)/ Location- Radial, RUE -O2: 99% intermittent, room air -RR: 17 per min -BP: 109/53 (L arm sitting) -Temperature: 36.9 C -Pain: 0/10 (Numeric Scale) -General

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