Traumatic Brain Injury - Case Study Part 3: Difference between revisions
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=== 6 Months Post Injury === | === 6 Months Post Injury === | ||
{| | {| width="800" border="1" cellpadding="1" cellspacing="1" | ||
|- | |- | ||
| | ! scope="col" | | ||
! colspan="2" scope="col" |Upper Limb | |||
! colspan="2" scope="col" |Lower Limb | |||
|- | |||
! | |||
|Right | |||
|Left | |Left | ||
|Right | |Right | ||
|Left | |Left | ||
|- | |- | ||
| | |Tone | ||
| | |Decreased | ||
| | |NAD | ||
| | |Decreased | ||
| | |NAD | ||
|- | |- | ||
|Power | |Power | ||
| Line 35: | Line 36: | ||
3-/5 Knee | 3-/5 Knee | ||
|4+/5 | |4+/5 | ||
|- | |- | ||
|Coordination | |Coordination | ||
| colspan="4" |Impaired | | colspan="4" |Impaired | ||
|- | |- | ||
| | |Range of Movement | ||
Muscle Length | Muscle Length | ||
| | |Shoulder: | ||
Flexion 110° | |||
Abd 90° | Abd 90° | ||
| Line 59: | Line 51: | ||
ER 50° | ER 50° | ||
Elbow: | |||
Full ROM | |||
Wrist: | |||
Full ROM | |||
|Shoulder: | |||
Full ROM | |||
Elbow: | |||
Full ROM | |||
Wrist: | |||
Full ROM | |||
|Hip: | |||
Full ROM | |||
Knee: | |||
Full ROM | |||
Ankle: | |||
Decreased ROM | |||
DF with Knee Ext | DF with Knee Ext -5° | ||
|Hip | |Hip: | ||
Full ROM | |||
Knee: | |||
DF with | Full ROM | ||
Ankle: | |||
Decreased ROM | |||
DF with Knee Ext 0° | |||
|- | |||
|Sensation | |||
| colspan="4" |Unable to participate in formal testing | |||
Does react to some tactile stimulation | |||
|- | |||
|Proprioception | |||
| colspan="4" |Unable to Assess | |||
|- | |||
|Reflexes | |||
|Decreased | |||
|NAD | |||
|Decreased | |||
Plantar - Upgoing | |||
|NAD | |||
Plantar - Downgoing | |||
|} | |} | ||
=== Current Function === | |||
• No use of oxygen
| • No use of oxygen
| ||
| Line 96: | Line 125: | ||
• Minimal Assist of 1 & Supervision of 1 on 6 Inch Curb
| • Minimal Assist of 1 & Supervision of 1 on 6 Inch Curb
| ||
=== Discharge Planning Considerations === | |||
* Family Support
| * Family Support
| ||
* Environment
| * Environment
| ||
* Equipment | * Equipment | ||
* Further Rehabilitation Needs | * Further Rehabilitation Needs | ||
== Discussion == | |||
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''' | 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 23:31, 29 September 2019
Presenting Condition[edit | edit source]
For background information go to
Traumatic Brain Injury - Case Study Part 1
Traumatic Brain Injury - Case Study Part 2
Assessment[edit | edit source]
6 Months Post Injury[edit | edit source]
| Upper Limb | Lower Limb | |||
|---|---|---|---|---|
| Right | Left | Right | Left | |
| Tone | Decreased | NAD | Decreased | NAD |
| Power | 2/5 | 4/5 | 2/5 Ankle
3-/5 Hip 3-/5 Knee |
4+/5 |
| Coordination | Impaired | |||
| Range of Movement
Muscle Length |
Shoulder:
Flexion 110° Abd 90° IR 40° ER 50° Elbow: Full ROM Wrist: Full ROM |
Shoulder:
Full ROM Elbow: Full ROM Wrist: Full ROM |
Hip:
Full ROM Knee: Full ROM Ankle: Decreased ROM DF with Knee Ext -5° |
Hip:
Full ROM Knee: Full ROM Ankle: Decreased ROM DF with Knee Ext 0° |
| 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 |
Current Function[edit | edit source]
• 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[edit | edit source]
- Family Support
- Environment
- Equipment
- Further Rehabilitation Needs
Discussion[edit | edit source]
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
