Traumatic Brain Injury - Case Study Part 2: Difference between revisions
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== Assessment == | == Assessment == | ||
=== Initial Physiotherapy Assessment in the ICU === | === Initial Physiotherapy Assessment in the ICU === | ||
GCS 6 (Eyes <sub>1</sub> Voice <sub>2</sub> Motor <sub>3)</sub> | * GCS 6 (Eyes <sub>1</sub> Voice <sub>2</sub> Motor <sub>3)</sub> | ||
* Pupils Right 6+, Left 5+ | |||
Pupils Right 6+, Left 5+ | * BP 116/84 Supine | ||
* Pulse 114 bpm | |||
BP 116/84 Supine | * O<sub>2</sub> Saturation 94% on 30% O<sub>2</sub> | ||
Pulse 114 bpm | |||
O<sub>2</sub> Saturation 94% on 30% O<sub>2</sub> | |||
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=== 2 Months Post Injury === | === 2 Months Post Injury === | ||
Tracheostomy Removed, Self ventilating on room air. | * Tracheostomy Removed, Self ventilating on room air. | ||
* PEG remains in situ for feeding. | |||
PEG remains in situ for feeding. | * Can attend Gym for Rehabilitation | ||
* Currently using wheelchair for mobility | |||
Can attend Gym for Rehabilitation | * GCS 10 (E<sub>4</sub> V<sub>2</sub> M<sub>4</sub>) Not following commands, No speech but occasional physical aggressive outburst | ||
* Mask like expression of face, wide open eyes and constantly raised eyebrows giving an alarmed or surprised impression, consistent with abnormal tone and sensation | |||
Currently using wheelchair for mobility | * Poor eye contact | ||
* Flexed posture with poor trunk and head control | |||
GCS 10 (E<sub>4</sub> V<sub>2</sub> M<sub>4</sub>) Not following commands, No speech but occasional physical aggressive outburst | * Repetitive non purposive movements of RLL | ||
* Subluxation of Left GHJ (Two Fingers Breadth) | |||
Mask like expression of face, wide open eyes and constantly raised eyebrows giving an alarmed or surprised impression, consistent with abnormal tone and sensation | |||
Poor eye contact | |||
Flexed posture with poor trunk and head control | |||
Repetitive non purposive movements of RLL | |||
Subluxation of Left GHJ (Two Fingers Breadth) | |||
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Revision as of 12:50, 24 October 2019
Presenting Condition[edit | edit source]
For background information go to
Traumatic Brain Injury - Case Study Part 1
Assessment[edit | edit source]
Initial Physiotherapy Assessment in the ICU[edit | edit source]
- GCS 6 (Eyes 1 Voice 2 Motor 3)
- Pupils Right 6+, Left 5+
- BP 116/84 Supine
- Pulse 114 bpm
- O2 Saturation 94% on 30% O2
| Upper Limb | Lower Limb | |||
|---|---|---|---|---|
| Left | Right | Left | Right | |
| Tone | Decreased | NAD | Decreased | NAD |
| Power | Unable to participate in manual muscle testing
Spontaneous movements are uncoordinated | |||
| Coordination | Unable to Assess
Spontaneous Movements Impaired | |||
| Range of Movement | Active - No Response to Cues, Spontaneous Movements observed
Passive - Within Normal Limits | |||
| Sensation | Unable to participate in formal testing
Does react to some tactile stimulation | |||
| Proprioception | Unable to Assess | |||
| Reflexes | Decreased | NAD | Decreased
Plantar - Upgoing |
NAD
Plantar - Downgoing |
| Behaviour | Restless ++ | |||
2 Months Post Injury[edit | edit source]
- Tracheostomy Removed, Self ventilating on room air.
- PEG remains in situ for feeding.
- Can attend Gym for Rehabilitation
- Currently using wheelchair for mobility
- GCS 10 (E4 V2 M4) Not following commands, No speech but occasional physical aggressive outburst
- Mask like expression of face, wide open eyes and constantly raised eyebrows giving an alarmed or surprised impression, consistent with abnormal tone and sensation
- Poor eye contact
- Flexed posture with poor trunk and head control
- Repetitive non purposive movements of RLL
- Subluxation of Left GHJ (Two Fingers Breadth)
| Upper Limb | Lower Limb | |||
|---|---|---|---|---|
| Left | Right | Left | Right | |
| Tone | Decreased | NAD | Decreased | NAD |
| Power | 0/5 | 4/5 | 0/5 Ankle
1/5 Hip 1/5 Knee (Not to Command) |
4/5 |
| Coordination | Unable to Assess
During Spontaneous Movements Cordination Impaired | |||
| Range of Movement | Glenohumeral Joint:
External Rotation 45° Internal Rotation 40° Flexion 90° Abduction 60° *Painful Grimace at End of Range GHJ Movement Elbow Full Range of Movement Wrist Full Range of Movement |
Full Range of Movement
All Joints |
Hip Full
Knee Full Ankle Decreased Achilles Length
|
Hip Full
Knee Full Ankle Decreased Achilles Length
|
| Sensation | Unable to participate in formal testing
Does react to some tactile stimulation | |||
| Proprioception | Unable to Assess | |||
| Reflexes | Decreased | NAD | Decreased
Plantar - Upgoing |
NAD
Plantar - Downgoing |
| Behaviour | Restless ++ | |||
| Staticic | Dynamic | |
| Sitting Balance | Assist x 2 | Unable - Tends to Extend |
| Standing Balance | Max Assist x 2 | Unable - Tends to Extend |
| Bed Mobility | Assist x 2 | |
| Lie to Sit | Assist x 2 | |
| Sit to Stand | Max Assist x 2 - Tends to Extend | |
| Gait | Unable to Initiate | |
| Wheelchair | Dependant - Currently in Tilt in Space | |
| ADLs | Dependent for All | |
Discussion[edit | edit source]
Considering what we now know, outline the key impairments and activity limitations for James. What outcome measures might you use with James and why? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can.
