Work Notes

2nd

Due to/because

Abdominal precautions

No siting up from lying flat, no lifting/pushing more than 10lbs, no reaching down to feet or straining abdomen

ADL

Activities of Daily Living (shower, dressing, toileting, etc.)

AFO

Ankle Foot Orthotic-brace that fits inside show to prevent foot drop

AKA

Above-knee amputation

Amb

Ambulation—walking

Aphasia

A language disorder that affects a person’s ability to communicate. Expressive (speaking) or receptive (understanding) language

Aspen Collar

cervical collar worn around the neck

B

Bilateral (both sides)

Bari BSC

Bariatric bedside commode (heavy duty for larger patients)

BKA

Below-knee amputation

BLE

Bilateral Lower Extremities (both legs)

Block

Placing your body in front of patient to improve safety.

“Block R” - block right side to prevent knee buckling

“Block L” - block left side to prevent knee buckling

BSC

Bedside commode

BUE

bilateral Upper Extremities (both arms)

c̅

with

CGA

Contact Guard Assist. P requires contact due to occasional loss of balance. No physical lifting/lowering.

CO-TX

Co-treat. PT&OT treat patient together. Pt unable to tolerate 2 full sessions. Don’t write Co-Tx time on board

Coccyx

Tailbone

CVA

stroke (cerebrovascular accident)

D/DEP

Pt is unable to provide effort or requires assist of 2.

Dependent/2 Person Transfer

One helper in front, one behind. Pt completes squat pivot transfer. Helper communication is key

DF

Dorsiflexion-raising foot/toes up towards shin. Inability to DF = footdrop —> AFO worn

Diplopia

Double vision. Pt may wear eye patch

Don/doff

Put on/take off

Drop Arm Commode

Commode arm rests drop down for squat/slideboard transfers

Dysarthria

Difficulty controlling muscles to speak

Dysphagia

Difficulty swallowing

Dyspnea

labored breathing

EOB

Edge of bed

FFWB

Flat Foot Weight Bearing. Affected limb may be placed on floor for balance, however no weight through limb

FWB

Full Weight Bearing. Pt able to place full body weight through limb

Fx

Fracture, broken bone

Gait

Walking

HA

Headache

HD

Hemodialysis — dialysis out of building

Hemi

Hemiplegia/hemiparesis. Weakness on one side of body.

“R hemi” = R weakness.

“L hemi” = L weakness

Hemi-walker

Walker designed for use with one arm

Hip Precautions

No bending at waist past 90 degrees, no crossing legs, and no turning toes in. Following hip replacement

HKB

Hinged Knee Brace

HOB

Head of Bed

HOH

Hard of hearing

I

Independent

Inattention

Difficulty recognizing/responding to stimuli on one side of body/environment. Pt may forget to place one leg in pants, may not see call light, may run into objects on one side. Can usually be cued to attend to the affected side. Mostly associated with CVA/TBI

L

Left

LBQC

Large Base Quad Cane

LE

Lower Extremity (legs)

LLE

Left Lower Extremity (left leg)

LUE

Left Upper Extremity

MAX A

Maximal Assist. Pt performs 25% of tasks, requires assist with 75%

Mildly Thick Liquid

Nectar Thick Liquids

MIN A

Minimal Assist. Pt performs 75% of tasks, requires assist with 25%

Minced/Moist Diet

Ground-like, lumps are easy to squash with tongue. Level 5 diet

MOD A

Moderate Assist. Pt performs 50% of tasks, requires assist with 50%

MOD I

Moderate Independent. Independent with use of assistive device, can include safety concerns

Moderately Thick Liquids

Honey thick liquids

NBQC

Narrow Base Quad Cane—cane with 4 small feet

NC

Nasal Cannula for supplemental Oxygen

Neglect

Difficulty recognizing/responding to stimuli on one side of body/environment. Pt may forget to place one leg in pants, may not see call light, may run into objects on one side. Associated with CVA/TBI

NPO

Nothing by mouth, unable to eat/drink. Tube feed. NPO sign on door

NWB

Non-weightbearing. no weight through affected limb. Pt should not place limb on floor during transfer.

OOB

Out of bed

Orthostatic hypotension

Drop in BP against gravity when charging position. Pt may report dizziness or lightheadedness. Monitor BP with change in position

PRAFO

worn on the feet while in bed to keep ankles in neutral and prevent wounds or contractures

Pressure Wound/Ulcer

Wound from inability to weight shift. Often on sacrum (bottom). No sliding/shear force

pureed

All food blended, no lumps. Level 4 diet

Pusher

Pt pushes with strong arm towards weak side, impaired sitting balance and transfers. Place strong arm on lap. Try transferring toward weak side

PWB

Partial weight bearing. Pt is allowed to place a certain body weight % through affected limb. % should be listed

Q

Every

R

Right side

Regular Diet

Normal, everyday foods/liquids of any texture. Level 7

Retropulsive/retrograde

leaning backward when sitting or standing. Often requiring cue or assist to lean forward

ROM

range of motion— joint mobility

RLE

Right Lower Extremity (right leg)

RUE

Right Upper Extremity (right arm)

RW

Rolling walker. Front Wheeled Walker

SBA

Stand-by assist. Pt requires supervision and possibility cueing to complete transfer safely. “close supervision”

SCI

Spinal Cord Injury

Slide Board

Pt leans while seated, board is placed under pt’s bottom. Pt’s arms are used to load weight and assist through scooting across board. “Sliding” should be avoided to maintain skin integrity

SOB

shortness of breath

Soft/bite size diet

Soft, tender, and moist throughout. Level 6 diet

SPC

single point cane. regular cane

SPT

Stand Pivot Transfer Pt completes sit-to-stand transfer, then takes small steps to turn in order to sit on transfer surface. Higher-level patients

Spinal Precautions

No BLT-no Bending/Lifting/Twisting. No bending down, no lifting more than 5-8lbs, no twisting spine. Log roll bed mobility

Squat Pivot

Squat Pivot Transfer. Pt does not complete full stand but instead completes “squat” to rise from surface. Arm rest of wheelchair removed will improve safety. Pt may require assist with scooting towards transfer surface prior to squat pivot

Sternal Precautions

No raising arms above head, no reaching arms out to side, no reaching behind back, no lifting more than 5-8lbs, no pushing up with arms

SUP

Supervision. Pt requires supervision and possibly cueing to complete transfer safely

TBI

Traumatic Brain Injury

TC

Tactile Cues-touching cues

Ted Hose

Compression stockings. “Thromboembolic Deterrent Hose”

Thin Liquids

Water-like liquids

TLSO

Back Brace. “Thoracic-Lumbar-Sacral Orthosis”

Transfer Board

Pt leans while seated, board is placed under pt’s bottom. Pt’s arms are used to load weight and assist through scooting across board. “Sliding” should be avoided to maintain skin integrity

TTWB

Toe Touch Weight Bearing. Affected limb may be placed on floor for balance, however no weight through limb.

UE

Upper Extremity

vc

Verbal cues

Visual Field Cut

Impaired vision on 1 side of visual field.

WBAT

Weight Bearing As Tolerated. Pt may place as much weight through limb as tolerated.

WC

wheelchair

FOOSH

Fallen On Outstretched Hand