Traumatic Brain Injury - Case Study Part 3: Difference between revisions

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'''6/12 Post Injury'''
{| class="wikitable"
|
| colspan="2" |Upper Limbs
| colspan="2" |Lower Limbs
|-
|
|Left
|Right
|Left
|Right
|-
|Tone 
|
|N
|
|N
|-
|Power
|2/5
|4/5
|2/5 Ankle


3-/5 Hip
3-/5 Knee
|4+/5
|-
|Sensation
| colspan="4" |Unable to Assess
|-
|Coordination
| colspan="4" |Impaired
|-
|Reflexes
|
|¯
|
|¯
|-
|ROM 
Muscle Length
|GHJ  Flexion 110°
Abd 90°
IR 40°
ER 50°
Ext 40°
Elbow Full ROM
Wrist Full ROM
|Full all joints
|Hip Full
Knee Full
¯Muscle Length TA
DF with Knee Ext.-5°
|Hip Full
Knee Full
¯Muscle Length TA
DF with Keee Ext. 0°
|}
'''Current Function'''
•   No use of oxygen 

•   Blood Pressure within normal limits 

•   Supervision with Mat Mobility 

•   Contact Guard with Stand Turn Transfers 

•   Contact Guard to Minimal Assist of 1 & Supervision of another for Gait 1200’

•   Minimal Assist of 1 & Supervision of 1 on 20 steps reciprocally with a Handrail 

•   Minimal Assist of 1 & Supervision of 1 on 6 Inch Curb 

'''Discharge Planning Considerations'''
* Family Support

* Environment

* Equipment 
* Further Rehabilitation Needs 
What treatment goals would you select for James? What considerations would you make towards James discharge planning? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can. '''Go to Discussion'''

Revision as of 00:16, 19 September 2019

6/12 Post Injury

Upper Limbs Lower Limbs
Left Right Left Right
Tone  N N
Power 2/5 4/5 2/5 Ankle

3-/5 Hip

3-/5 Knee

4+/5
Sensation Unable to Assess
Coordination Impaired
Reflexes ¯ ¯
ROM 

Muscle Length

GHJ  Flexion 110°

Abd 90°

IR 40°

ER 50°

Ext 40°

Elbow Full ROM

Wrist Full ROM

Full all joints Hip Full

Knee Full

¯Muscle Length TA

DF with Knee Ext.-5°

Hip Full

Knee Full

¯Muscle Length TA

DF with Keee Ext. 0°

Current Function

•   No use of oxygen 


•   Blood Pressure within normal limits 


•   Supervision with Mat Mobility 


•   Contact Guard with Stand Turn Transfers 


•   Contact Guard to Minimal Assist of 1 & Supervision of another for Gait 1200’


•   Minimal Assist of 1 & Supervision of 1 on 20 steps reciprocally with a Handrail 


•   Minimal Assist of 1 & Supervision of 1 on 6 Inch Curb 


Discharge Planning Considerations

  • Family Support

  • Environment

  • Equipment 
  • Further Rehabilitation Needs 

What treatment goals would you select for James? What considerations would you make towards James discharge planning? Have a conversation with your colleagues, please share your knowledge with others and answer their questions where you can. Go to Discussion

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