S: Pt was drowsy upon entering room.

When speaking with pt, pain was reported as 10/10 at

initiation of session.

O: Pt was seen in ICU for 30 minutes following multiple GSW to abdomen, striking L4 and L5
transverse processes and medulla of R kidney resulting in an increased need for safety
awareness and a decrease in ability to independently perform ADLs. Pt has past history of
cocaine and heroin abuse, and tested positive for cocaine upon admission. Prior to pt
movement, activities of session were discussed with pt. Pt lines and tubes were managed to
prevent occlusion, blockage, or dislodging during movement. Pt was dependent in LE dressing
task of donning socks. Pt was educated on logroll techniques and completed bed mobility with
mod A for safety, increased time, and assistance with righting trunk. Pt was able to move UE to
bedrail for support and assist in bringing LEs over EOB. Once upright, pt reported increased pain
but was encouraged with VCs to continue through movement. Pt family entered room, but left
soon after, stating they did not want to interrupt therapy session. Pt rested for 1 minute. After
break, bedside chair was prepared for pt transfer. Pt was max A and +1 assist for stand pivot
transfer to chair. Pt required min A for line management and abdominal safety for postural
adjustment in chair. In chair, pt continued to report pain and self-administered medication
through PCA button. Pt was adjusted in chair and requested family to return to his room.

A: Pt was encouraged to work through pain, as he has history of opioid abuse and is currently
experiencing withdrawal symptoms. Therapy was continued to increase patient capacity for
rehabilitation while considering the pts low pain tolerance and high opioid tolerance. Pt
displays impulsivity and decreased safety awareness based on sudden movement back to
supine while seated at EOB. Based on pt performance, pt will be mod-max A for bed mobility
for LE movement, increased time, and safety. Due to increased pain reducing ROM utilized, pt
will be mod A for LE dressing. Pt goals will also include education surrounding safety after
surgery.

P: After stay at Grant Medical Center, pt will discharge to home. Prior to discharge, pt will be
issued appropriate adaptive equipment based on improvements made while recovering in
hospital. Due to past abuse of opioids and cocaine, pt will continued to be encouraged to work
through pain and discomfort in future sessions. As discharge approaches, pt will be further
educated on benefits of refraining from recreational drug use. Pt will continue to be seen in ICU
for 30 minutes until transferred from unit. Pt will be seen in 1 day to continue to address bed
mobility, safety awareness, and ADL performance.