Hip Fracture: Standing ADL OT Session – Detailed Study Notes

Client Profile

• 79-year-old female (“Jimmy”)
• Admitted to a Skilled Nursing Facility (SNF) 3 weeks ago after sustaining a left-femur (hip) fracture; likely status-post ORIF or hemi/total hip replacement (exact surgical procedure not stated)
• Currently ambulates via wheelchair; beginning to trial standing activities with a front wheeled walker (FWW)

Context & Session Parameters

• Setting: SNF therapy gym/bathroom area (functions as inpatient rehab milieu)
• Discipline leading session: Occupational Therapy (OT)
• Session length: ≈ 4 min 51 s (rounded to 5 min for documentation)
• Primary occupation assessed: Activities of Daily Living (ADL) – grooming & hygiene at sink
• Secondary occupations addressed/considered:
  • Transfers (sit-to-stand, stand-to-sit)
  • Functional standing tolerance
  • Balance & fatigue management
• Equipment: Wheelchair (WC), front-wheeled walker, sink, washcloth, soap, Ziploc bag with toothbrush & toothpaste, disposable cups

Precautions

• Post-hip-fracture/possible post-hip-replacement precautions (exact approach unknown; assume standard hip precautions until clarified)
• Fall risk & orthostatic hypotension monitoring
• Fatigue monitoring
• Vital-sign parameters established pre/post activity

Vital Signs

• Baseline seated:
  • Blood pressure (BP): \text{?}/? (systolic not verbalized; diastolic 84–85 mmHg mentioned)
  • Heart rate (HR): 85\,\text{bpm}
• Post-activity (immediately after ≈5 min standing ADL):
  • BP: 148/95\,\text{mmHg}
  • HR: 100\,\text{bpm}
• Therapist rationale: mild HR elevation expected with exertion; patient educated on monitoring for excessive rise, dizziness, or fatigue

Activity Flow & Sequencing

1. Therapist explains plan: stand at sink to complete grooming to gauge home-readiness
2. Patient instructed to lock wheelchair before standing (required verbal cue)
3. Sit-to-stand transfer with walker placed at sink
4. Standing grooming tasks:
   • Wet washcloth, apply bar soap, wash face (primarily LUE; RUE for walker stability)
   • Retrieve Ziploc bag, open with BUE fine-motor pinch
   • Remove toothpaste & toothbrush, uncap toothpaste, apply, wet brush, brush teeth (RUE dominant during brushing)
   • Use disposable cup to rinse mouth x1
   • Locate washcloth (needed prompt), wipe face dry
   • Replace items into bag & tidy sink area
5. Stand-to-sit transfer; verbal cues for stepping back, feeling chair, reaching for armrests
6. Post-vital assessment & subjective report of exertion (“felt alright that time”)

Motor & Process Observations

• UE Range of Motion: full functional BUE AROM noted (bilateral shoulder flex ≈ >90^\circ, elbow/wrist WNL)
• Hand function: fine-motor dexterity intact (opened Ziploc, uncapped toothpaste, manipulated small objects)
• Weight-bearing: Equal through B LE while standing; slight reliance on walker for balance
• Gait not assessed; static standing tolerance ≈ 3–4 min without seated rest
• Balance:
  • Static standing: fair (maintained with one hand on walker)
  • Dynamic standing: minimal challenge (reaching within BOS); required walker support during far reaches
• Endurance/Fatigue: mild; HR ↑ 15\,\text{bpm}, BP ↑; patient denied dizziness
• Safety awareness: required initial cue re: WC locks & locating washcloth; otherwise followed multi-step sequence accurately
• Cognitive status: Appears A&O ×3, follows directions, engages in conversation; mild memory lapse (washcloth location)

Pain

• No explicit pain verbalized; implied tolerable. Location not specified.
• Recommend numerical rating scale (NRS 0–10) next session

Therapist Cues & Education

• Verbal cues: wheelchair locks, sequencing, safety with transfers, monitoring vitals
• Education topics:
  • Rationale for HR changes with exertion
  • Encouragement to alert therapist if dizzy/fatigued
  • Reinforcement of hip precautions implicit in transfer technique
• Environmental set-up: walker pre-position, washcloth & grooming supplies staged, chair behind for immediate rest

Outcome Measures / Potential EMR Entries

• Possible tools for future quantification:
  • Modified Barthel Index (MBI) for ADL independence
  • Berg Balance Scale (BBS) for standing balance
  • Timed Up & Go (TUG) once ambulation allowed
• Functional skill scores observed today (informal):
  • Grooming & hygiene: supervision-level; independent motor steps, 1–2 verbal safety cues
  • Transfers: supervision-level with verbal cue for chair lock & positioning
  • Standing tolerance: ~4 min with walker, no rest breaks

Implications & Significance

• Demonstrates capacity to manage basic grooming while standing, an essential precursor for safe bathroom mobility at home
• Mild safety cueing suggests need for continued OT to solidify routines & precaution adherence
• Vital sign response within acceptable limits; supports graded progression of standing and eventual ambulation training
• Independence in bilateral upper-extremity use positive for self-care ADLs; lower-extremity strength/endurance remain focus

Preliminary OT Diagnosis (for EMR draft)

• Impairments: decreased lower-extremity strength/endurance, reduced standing balance, limited functional mobility, mild safety insight deficits
• Participation limitations: grooming at sink, transfers, home bathroom tasks
• Skilled OT required to: train safe functional mobility/ADLs, educate on hip precautions, improve balance & endurance, facilitate discharge to home with least restrictive support

Prognosis & Rehabilitation Potential

• Based on session performance, cognitive status, and motivation, rehab potential judged GOOD for achieving independence/supervision in self-care within SNF LOS and progressing to home with possible HHOT/OP follow-up

Goal Framework (examples to populate EMR)

Short-Term (2 weeks)

• Pt will complete grooming at sink for 5 min with ≤1 verbal cue for safety, HR rise ≤20\,\text{bpm} above baseline
• Pt will perform sit-to-stand transfer with walker using hip precautions with supervision, no verbal cue
• Pt will demonstrate understanding of 3 hip precautions with 100 % verbal recall

Long-Term (4–6 weeks / discharge)

• Pt will independently perform full AM hygiene sequence (wash face, brush teeth, shave/make-up) in standing × 10 min with walker, maintaining BP <160/100\,\text{mmHg} and HR <110\,\text{bpm}
• Pt will ambulate 150 ft with walker and perform toilet transfer with contact guard assist per PT/OT co-treatment
• Pt will be discharged home requiring no more than PRN family check-ins for safety

Intervention Categories Addressed Today

• ADL/Self-Care Training
• Therapeutic Activity (graded standing tolerance with task)
• Patient/Caregiver Education

Recommended Service Delivery

• Frequency: 3×/wk OT
• Duration: 12 visits over 4 weeks (modifiable per progress)
• Referrals: continue PT for gait; consider SLP if cognitive status declines

Discharge Planning Snapshot

• Not yet appropriate; needs further balance, mobility, and ADL tolerance
• Anticipated disposition: Home with possible HHOT → OP

Key Takeaways

• Client safely tolerated short standing ADL session with minimal vitals change.
• Demonstrated bilateral UE dexterity and sequencing; primary limitations remain LE strength/balance and intermittent safety awareness.
• Continued skilled OT warranted to meet independence goals and facilitate safe discharge.