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Case Study

Acute Care Setting

Jessica Preuschoff

SVSU

April 11th 2014

Case Study in Acute Care

1. Personal data and history

The client is a 66 year old male who was admitted after a fall of a truck. The client is an automobile transporter. He said that his left leg got caught while he was loading a car onto the truck which caused him to fall five feet onto concrete. The patient is from out of state and was just here on a job. He lives in a house with his wife, a cat, and a dog. He was two months shy of retirement when the accident occurred. He is a marine veteran. According to his past medical history he has hypertension, hyperlipidemia, and atrial fibrillation. He has received surgery for cataract removal, had surgery on his right knee and had a spur removed in his left elbow. He is a smoker but was forced to quite due to being in the hospital and not being able to go out and smoke. The client enjoys going out to dinner with his wife, camping, hiking, and walking the dog in his leisure time.

2. Diagnosis

He was admitted with a diagnosis of left tibia and fibula fracture, first metacarpal fracture right, and right-sided scalp hematoma (diagnosis made with x-ray and CT) due to a five foot fall onto concrete. The fracture is closed but comminuted involving the proximal tibia extending to the lateral tibia plateau with displaced and depressed fragments. The comminuted fracture of the proximal tibia shaft extends into the surface of the tibia with separation of the fracture fragments. The fracture of the proximal tibia is intra-articular. He has a comminuted fracture of the proximal fibula as well which is oblique. He likely has a fracture involving the lateral femoral condyle as well. He developed compartment syndrome in the left lower leg which has been treated with fasciotomies and skin grafts from right upper lateral thigh. He has a posttraumatic deformity of the distal fibula which is at this point in time already healed. He has a closed intra-articular fracture of the left first metacarpal (thumb). The head CT showed a right-sided scalp hematoma but no TBI. He also has a right periorbital ecchymosis and an abrasion to the right side of his face. His movement of finger and toes of the affected extremities are impaired.

Surgical intervention: The client underwent six surgical procedures during his stay:

1. Left leg four compartment fasciotomy, left tibia plateau closed reduction, application of the LE knee spanning external fixator, irrigation and debridement involving the skin of the left LE and wound vac application

2. Open reduction and internal fixation of the right intra-articular metacarpal fracture

3. Irrigation and debridement of left leg fasciotomy wound as well as an application of the wound vac

4. Irrigation and debridement of left LE fasciotomy wound

5. Irrigation and debridement of left LE fasciotomy wound , preparation of LE for skin graft (STSG), application of wound vac and short leg splint to the left LE

6. Removal of the knee spanning external fixator and open reduction and internal fixation of tibial plateau fracture

a. Narrative summary and review of the specific conditions seen. Describe how the client’s conditions parallel.

Comminuted, closed, intra-articular fracture of the tibia: A closed fracture means that the bone did not pierce the skin and comminuted means that the bone has shattered. A fracture that is intra-articular is a fracture in or in close proximity to a joint (Common Skeletal Injuries/Conditions, n.d.). This is exactly how the fracture presented itself in the client.

Comminuted, closed fracture of the fibula: This fracture is called closed because it did not pierce the skin and it is also comminuted which means that the bone shattered (Common Skeletal Injuries/Conditions, n.d.). This is exactly how the fracture presented itself in the client.

Compartment syndrome: Compartment syndrome is increased pressure in a compartment of the body which is a confined space. Etiology of compartment syndrome is prolonged direct pressure on crushed extremities, intraoperative complications, high dose of barbiturates, intraaterial barbiturate or propoxyphene injections, snake bites, hemophiliac bleeding, thermal and electrical burns, and overwork of the muscles. Symptoms of compartment syndrome are pain that is over proportional to the actual injury or procedure being done as well as signs of muscle and nerve ischemia (parasthesia). Fasciotomies are incisions into the fascia that relieve pressure and allow for normal muscle movement (Bassini & Patel, 2007). The client experienced a difficult break and eventually suffered from compartment syndrome. He had over proportional pain and the compartment syndrome was most likely caused by the fall. The client received a skin graft (autograft) to cover the side of the faciotomy.

Skin graft: A skin graft in the form of an autograft was used with this client. An autograft is a skingraft that is harvested from the client’s own body (Deshaies 2007). The autograft was a split thickness skin graft (STSG). The autograft was taken from the client’s right lateral, proximal lower extremity.

Intra-articular fracture of the right first digit metacarpal: This fracture is presents itself in or near a joint (Common Skeletal Injuries, n.d.). This is how it presented in the client.

Fracture of the lateral femoral condyle: The type of fracture was not more defined in the client information given.

Right-sided scalp hematoma: The client acquired a hematoma due to falling onto concrete. He met the concrete with the right side of his face and head. A hematoma is a considerable amount of blood that is restricted to a specific space with no possibility of release until the body is able to degrade the blood (Cooper, 2007). The hematoma vanished on its own after about two weeks.

Periorbital ecchymosis and abrasion to the side of the face: A periorbital ecchymosis is a black eye. The client acquired a black eye on the right side of his face when he fell from the transporter. Ecchymosis is a discoloration of the skin that is caused by burst blood vessels that release blood into the tissue (Cooper, 2007).

3. Physical frame of reference and rationale for selection

The physical frames of reference chosen for this client is the rehabilitative frame of reference as well as the biomechanical frame. The rehab frame is used when the client’s condition has plateaued and it is unlikely that he or she will increase functionality therefore adaptive techniques and tools are applied (Pendleton, & Schultz- Krohn, 2013). In the case of the client in this case study it is likely that he will improve over time but is not able to bear weight into the affected extremity for the next couple of months. Therefore he will need adaptive equipment and compensatory techniques. The biomechanical frame of reference deals with muscle strength, ROM, edema, and endurance (Pendleton, & Schultz- Krohn, 2013). He is experiencing edema in his leg as well as decreased ROM in his leg and digit one of his right upper extremity. Measures can be taken to decrease the edema but the leg may not be mobilized at this time.

4. Observation of evaluative items. Be sure to include OTPF domains, process of OT, types of OT interventions, types of OT intervention approaches, types of outcomes.

Domains of occupational therapy

Areas of occupation: Affected areas for the client are ADLS, IADLs, rest and sleep, work, leisure and social participation. The client is unable to do is own ADLs like dressing and toileting due to his inability to move the affected leg or bear weight into it. He is right-handed and with the fracture of the first metacarpal he is unable to oppose his thumb and therefore write e.g. checks. . He is also not supposed to bear weight into his right upper extremity. He is also unable to drive a car or go shopping. His sleep and rest is affected not only by the pain of the injuries but also by the fact that he cannot move his body into positions that are comfortable for him to sleep in. He is also woken up by the nurses who come to check on him regularly and also give him medication and other treatment like ice packs. His work is affected as well. He is unable to work in the foreseeable future and is on worker's compensation at the moment. In his leisure time he enjoys walking the dog, hiking, and going out to dinner with his wife which are all activities he is unable to do at the moment. He is unable to see his wife or his family as the accident occurred out of state and he therefore is not able to see them as often as he is used to.

Client factors (values, beliefs, and spirituality, body functions, body structures): The client’s values, beliefs, and spirituality are unaffected by the injury. His body functions specifically his neuromuscular and movement-related functions as well as skin and related-functions are affected. His hematological functions are affected as well. The client’s joint mobility and stability is affected due to the injury as well as the splinting that has taken place as a treatment measure. His muscle power on his affected and even his non-affected side (lower extremity) is affected as he has not been able to work these muscles since the injury. His arm muscles are affected as well which can be seen when he stands up with the help of a walker and has to push through his arms. His endurance is low due to the fact that he has been lying down for a longer period of time. His gait pattern is stiff and slow due to his injury and knee pain in his non-affected lower extremity. His cardiovascular system is affected at times. His blood pressure will often be very high due to his arterial fibrillation but during other times it will be low because he has not been up enough in the last couple of weeks. His hematological system gave him some problems right after the surgery as he had lost a lot of blood. He was anemic and his HGB was low. He received a blood transfusion which remedied this. His skin function was affected right after the surgery that released the compartment syndrome. He also received debridement surgeries. His skin would blister and the attending physicians would take him back to the OR to get the wound site cleaned out to eventually be able to apply the skin graft. The body structures affected are the structures of the cardiovascular system (arterial fibrillations of the heart), skin and related structures, as well as structures related to movement.

Performance skills: The performance skills affected by this injury are motor and praxis skills. The client is not able to walk, transfer himself from a bed to a chair, change position in bed or do his ADLs independently. This is mostly due to his inability to move his affected left LE. He is able to do things for himself such as eating and brushing his teeth if the equipment is set up at his bedside and if he uses his left nonaffected UE. His sensory perceptual skills seem to be intact but his leg is in a cast. Sensation in his toes has been tested and so far he has not reported any numbness or tingling in the rest of his leg nor any hypersensitivity.

Performance patterns: His routines, roles, and rituals are affected by the injury. He used to be the breadwinner of the family but is now unable to provide for himself and his wife. He also has the role of a husband. He is still able to fulfill part of this role as he communicates with his wife daily over the phone but he cannot be physically there with her to support her with daily decision making. He used to be a smoker but is unable to smoke now since he is in a hospital that is a smoke free environment (ritual). He is unable to complete his regular morning routine as he is dependent on the help of the nurses which means he has to wait for them to come and help him and they may set up his tools differently from what he is used to.

Context and cultural environment: Being in a hospital unrelated to the fact that he is injured will influence the client’s performance (physical environment). He does not have all his objects handy and the objects he is presented with are not in the spot he is used to. For example he does not like the TV as the channels are in different locations than he is used to and the TV control set up is very basic (channels only progress forward). His social environment is limited to the people that are working in the hospital and interact with him on a regular basis, e.g., physicians, nurses, therapists, and case workers. His personal context is that he is a 66 year old man that was supposed to retire in two months.

Activity demands (objects used and their properties, space demands, social demands, sequencing and timing, required actions required body functions, required body structures)

The activity chosen for this analysis is donning pants.

Objects and their properties: The client is unable to bend down far enough to reach his toes and therefore he is in need of a reacher. He needs to be seated at the edge of bed or a chair.

Space demands: The client needs some physical space in front of his bed or in front of a chair in his room to pull up the pants. The temperature should be at room temperature so that the client will not get cold and the light should be adequate so that the client is able to see the objects while he is engaging in the activity.

Social demands: It is expected of the client that he performs the activity as independent as possible and that the occupational therapists only step in if necessary. On the other hand the client also expects the support from the occupational therapist if he needs it.

Sequence and timing: The client knows the sequence of putting on his pants in general but has to relearn new methods in regards of his leg. He needs to clip the reacher to the top anterior portion of the pants, throw them forward, put his affected leg in first, and pull up the pants. He then has to repeat the same on the other side.

Required actions and performance skills: The client needs to be able to do the required motor and praxis skills needed for this movement. He needs to be able to feel and pinch the reacher as well as bend over slowly.

Required body functions: The client needs to be able to move all the joints freely that are required for this activity. He needs to be able to manipulate the reacher and the pants with his fingers and bend forward slightly. He also needs to be able to keep his balance when leaning forward. He also needs to be able to understand the instructions given.

Required body structures: The required body structures for this activity are hands, eyes, ears, hips and the upper and lower extremity (nonaffected side)

Process of OT

As per the process of occupational therapy the client was evaluated prior to the start of the treatment session. The client is asked to give his identifying information to make sure the correct client is being treated. He will then give a number for pain on an analog pain scale from 1 to 10. This will happen right before each treatment session. The evaluation in the first treatment session also included background information, e.g. his living situation and how the accident happened. The thumb fracture was evaluated. The client had significant swelling at first which was soon controlled by icing. His progress with functionality was tested at the beginning of each session with hand exercises (thumb opposition). Since the leg has been non weight bearing so far and is in a cast that goes above the client’s knee it is not further assessed aside from asking the client about the pain level and any numbness or tingling that he may currently experience in the leg. The client will be asked about his weight bearing status in upper right and lower left extremity prior to each treatment session and any questions will be answered during the treatment session.

Types of OT interventions

The occupational therapy approaches used for this client are preparatory methods, purposeful activities, and occupation-based activities.

Preparatory methods are those that help the client to prepare for the actual occupation based activity. They are used prior to engaging in purposeful and occupation-based activities (American Occupational Therapy Association, 2008). Preparatory methods that are being used for this client are icing of the first metarcarpal and leg. He also engages in hand-flexibility exercises to regain function in his thumb which has been quite stiff due to the fracture of the first metacarpal. The exercises that he performs are thumb opposition exercises. The client is also educated on precautions he has to adhere to, to ensure proper healing of his leg and thumb, e.g. not to bear weight into the affected leg when standing up and not to bear weight into his thumb/hand when using the walker.

Purposeful activities are those that make it possible for the client to regain skills that he needs for occupation-based activities (American Occupational Therapy Association, 2008). The client engages in these activities when he practices functional mobility with a platform walker. This will eventually make it possible for him to ambulate to the bathroom independently to perform BADLs.

Occupation-based interventions are those interventions that make it possible for the client to work directly on the task that gives him problems (American Occupational Therapy Association, 2008). The client in this case study practices lower body dressing with a reacher to pull on pants and a sock aid to put on the sock on his non-affected leg.

The education process is also used with this client. In this process the occupational therapist shares knowledge with the client about occupation, health, and participation. It may not actually lead to the actual performance of the task described (American Occupational Therapy Association, 2008). The task of using a sock aid was not implemented the first time it was shown to the patient. The sock aid was explained and demonstrated by the occupational therapist.

The consultation process was also used with this client. In this process the occupational therapist helps the client identify a problem and finding a solution for it (American Occupational Therapy Association, 2008). The client needed a leg lift to move his leg. He reported to the therapist that changing position in bed was difficult due to the heavy cast and that he was not able to do it independently. The acute care setting does not have a leg lift that could solely stay with this client. After the client had reported the problem the therapist and the client came to the solution that a theraband may be helpful to the client. The therapist presented the client with the theraband.

Types of OT intervention approaches:

Establish; restore (remediation, restoration): This intervention approach helps clients to regain a function that had been lost or impaired prior. Functional mobility is treated by the occupational therapist to make it possible that the client can walk to the bathroom independently to take care of BADLs.

Modify (compensation, adaptation): This intervention approach helps the client learn adaptive techniques when function is not likely to return or not likely to return soon. The client in the case study is learning to walk with a platform walker as he is not supposed to bear weight into his affected leg. He is going to a rehab facility otherwise the occupational therapist would also focus on adaptations that would need to be made to his home (American Occupational Therapy Association, 2008)

Types of outcomes

The occupational therapy outcomes for this client are occupational performance, adaptation, health and wellness, participation, quality of life, and role competency. In the case of the client, improvement of occupational performance is a planned outcome. As of now he needs at least moderate assist for simple BADLS, functional mobility, bed mobility, sitting at the edge of the bed, sit to stand, and transfers. The outcome should, be that he is independent in most of these tasks and if not that he can at least progress to minimal assist. Another outcome is adaptation in the sense that the client is able to incorporate adaptations to daily tasks and routines. That for example he is able to functionally ambulate to the bathroom with the platform walker but will then sit down to be able to complete his morning routine independently instead of standing up.

The client is depressed at times and angry at other times due to his inability to take care of himself and due to the fact that he is so far away from his home. It would be beneficial for his health and wellness if he could partake in chosen leisure activities which would also lead to participation. Once he is transferred to a rehabilitation facility his wife could come visit him and also bring their dog. He enjoys spending time with the dog. Even though he cannot take him on walks as of now but he can enjoy the dog's company. Seeing his wife would also increase his health and well-being. He also enjoys going out to dinner with his wife. He could be situated into a wheelchair with a leg raise and be wheeled down to the cafeteria. Him and his wife could then enjoy a meal together. All the options mentioned above will lead to a better quality of life. His role competency is affected by the fact that he is unable to work and provide for his family as of now. He is on worker’s compensation. He is still a husband and while he cannot provide money he can still be there for his wife with advice and support.

5. Pharmacological assessment and impact on therapeutic intervention (current medications, precautions, importance, effects on OT, …)

|medication |instructions |Precautions and side effects |importance |Effects on OT |

|Bethanechol 25mg oral |1 tab orally 3 times a |Can cause dizziness, vomiting, |Helps the client empty |Dizziness can cause |

|tablet |day |diarrhea, headache |his bladder. |someone to fall therefore |

| | | | |the client has to be |

| | | | |watched carefully when |

| | | | |doing standing or sitting |

| | | | |activity. The client may |

| | | | |also experience a headache|

| | | | |when sitting up which can |

| | | | |influence his motivation |

| | | | |to take part in therapy. |

|Docusate sodium 100mg oral |1 cap orally once a day |Stomach, pain, diarrhea or cramping |Helps the client to move |If the client experiences |

|capsule |at bedtime and 2 caps |may occur. |his bowel. It works as a |pain in the abdominal area|

| |orally once a day | |stool softener. |or has to go to the |

| | | | |bathroom frequently a |

| | | | |therapy session may have |

| | | | |to be terminated or may |

| | | | |have to be adapted to the |

| | | | |client’s needs. |

|Bisacodyl 10mg rectal |1 suppository rectal |Rectal irritation/burning/itching, |Helps the client to move |This medication takes |

|suppository |once a day, as needed, |mild abdominal discomfort/cramps, or |his bowel. |effect 15 to 60 minutes |

| |constipation |nausea may occur. | |after it has been |

| | | | |administered and therapy |

| | | | |should not be planned into|

| | | | |those minutes as the |

| | | | |client is getting ready to|

| | | | |move his bowel. |

|Digoxin 125 mcg (.125mg) |1 tab orally |Nausea, vomiting, loss of appetite, |Used to control the |The client may not feel |

|oral tablet | |headache, and diarrhea may occur |client’s arterial |motivated to take part in |

| | | |fibrillation. |therapy if he feels any of|

| | | | |the mentioned side |

| | | | |effects. |

|Collagenase 250 units/g |1 application topically |Mild skin irritations, burning and |This is used on the |If the client’s skin feels|

|topical ointment |once a day |itching may occur |client’s healing skin on |uncomfortable or itchy he |

| | | |his leg. Especially in |may be distracted when |

| | | |the area that has been |taking part in therapy. |

| | | |debrided. | |

|Metoprolol tartrate 50mg |1 tab orally every 12 |Drowsiness, dizziness, tiredness, |This is used to treat the|If the medication is |

|oral tablet |hours |diarrhea, and slow heartbeat are |client’s high blood |stopped suddenly or the |

| | |possible. Blood flow to the hands and|pressure. |dose is changed the client|

| | |feet may be decreased. | |may suffer from low or |

| | | | |high blood pressure |

| | | | |depending on what the |

| | | | |change was. This will |

| | | | |affect therapy in the |

| | | | |sense that the client may |

| | | | |not be able to perform |

| | | | |activities that cost him a|

| | | | |lot of strength like |

| | | | |functional mobility. |

| | | | |Drowsiness and dizziness |

| | | | |can also lead to the |

| | | | |client falling or having |

| | | | |other accidents related to|

| | | | |loss of balance. |

|Zolpidem 5mg oral tablet |1 tab orally once a day |Dizziness can occur and it may also |Helps the client to fall |Since the client is only |

| |at bedtime, as needed, |make the client sleepy throughout the|asleep. |taking this medication at |

| |insomnia |day. | |bedtime and only if he has|

| | | | |trouble falling asleep it |

| | | | |does not have a direct |

| | | | |influence on occupational |

| | | | |performance. It is more |

| | | | |likely that if he does not|

| | | | |take the medication he |

| | | | |will be sleepy throughout |

| | | | |the day. |

|enoxaparin |30 units subcutaneous 2 |The injection side may burn or itch. |It is used to prevent |Since this medication is a|

| |times a day |The client may also experience |blood clots. |blood thinner it is |

| | |fatigue or fever. | |important to be careful |

| | | | |with the client so that he|

| | | | |does not cut himself or |

| | | | |get bruised as this can |

| | | | |cause bleeding. |

|Tamsulosin .4mg oral |1 cap orally |The client may experience dizziness |It is used to treat an |This medication will |

|capsule | |or drowsiness, lightheadedness, a |enlarged prostate. It |affected occupational |

| | |runny/stuffy nose or has problems |relaxes muscles in the |performance if the client |

| | |with ejaculation. |prostate and the bladder.|experiences dizziness or |

| | | |It supports the client in|drowsiness as it could |

| | | |his ability to urinate. |lead to falls and other |

| | | | |balance related injuries. |

|Magnesium hydroxide 8% oral|30ml orally, as needed, |It may cause diarrhea. |It supports the client in|If the client has to go to|

|suspension |constipation | |the ability to move his |the bathroom frequently a |

| | | |bowel. |therapy session may have |

| | | | |to be terminated or may |

| | | | |have to be adapted to the |

| | | | |client’s needs. |

|Acetaminophen-oxyCOD one |1 tabs orally every 4 |This mediation may cause nausea, |This is used to treat the|This medication will |

|325mg-5mg oral tablet |hours as needed, |vomiting, constipation, dizziness, |client’s pain. |affected occupational |

| |moderate pain 4-7 |drowsiness or lightheadedness. | |performance if the client |

| | | | |experiences dizziness or |

| | | | |drowsiness as it could |

| | | | |lead to falls and other |

| | | | |balance related injuries. |

| | | | |It may also influence his |

| | | | |performance positively as |

| | | | |he will be more likely to |

| | | | |move and be motivated in |

| | | | |taking part in therapy if |

| | | | |he experiences less pain. |

|Brimonidine .15% ophthalmic|1 drop to each affected |This medication may cause some |This medication is used |Since it can affect the |

|solution |eye three times a day |discomfort to the eye like itchiness |to treat glaucoma and eye|client’s vision it is |

| | |or redness. It can also cause blurry |fluid pressure in the |important to ask the |

| | |vision dizziness or drowsiness. |eye. |client if his vision is |

| | |Tiredness may occur. | |normal a couple times |

| | | | |throughout the session to |

| | | | |prevent falls or injuries.|

| | | | |This medication will |

| | | | |affected occupational |

| | | | |performance if the client |

| | | | |experiences dizziness or |

| | | | |drowsiness as it could |

| | | | |lead to falls and other |

| | | | |balance related injuries. |

|Aspirin 325mg oral tablet |1 tab orally once a day |The medication may cause and upset |The client may receive |A decrease in pain will |

| | |stomach or heartburn. |this medication to |have a positive influence |

| | | |relieve pain and to |on therapy as the client |

| | | |decrease his risk of |will be more motivated to |

| | | |blood clots. |take part in therapy. |

| | | | |Since this medication can |

| | | | |be used as a blood thinner|

| | | | |it is important to be |

| | | | |careful with the client so|

| | | | |that he does not cut |

| | | | |himself or get bruised as |

| | | | |this can cause bleeding. |

|Atorvastatin 20mg oral |1 tab orally once a day |Muscle pain or tenderness may occur |Helps lower bad |This medication will most |

|tablet | |but the possibilities of this |cholesterol and raise |likely have no influence |

| | |occurring are slim. |good cholesterol. |on therapy. |

|PreserVision oral tablet |1 tab orally twice a day|Supplement of minerals and vitamins |Supplement that is |No indications given that |

| | |for the eye. |supposed to help decrease|it will affect therapy. |

| | | |macular degeneration. | |

WebMD, LLC, 2014; Bausch & Lomb Incorporated, 2014

6. Treatment plan

a. Assets/strengths list

• His humor and positive outlook on life.

• The support from his wife even when only over the phone.

• The interdisciplinary team that works well together to make a quick recovery possible for the client.

• He is educated and genuinely interested in the treatment he is receiving.

b. Problem list

• His age (66 years of age)

• He has other health conditions that could affect his performance in treatment, e.g. arterial fibrillation

• He has trouble bearing weight through his unaffected leg and arm due to a knee surgery (RT) as well as an elbow spur removal (LT).

• He cannot bear weight into his affected lower and upper extremity

• He struggles with thumb opposition and is unable to use that hand to bear weight when using a walker (e.g. a platform walker is used).

• He is dependent for most of his ADLs, functional mobility, bed mobility, sit to stand, and transfers.

c. STG/LTG

STG

The client will demonstrate the ability to shift his weight in bed with the use a leg lift independently within two treatment sessions.

The client will demonstrate the ability to sit at the edge of the bed with the use of a leg lift independently within two treatment sessions.

The client will demonstrate the ability to transfer from sit to stand using a platform walker independently within three treatment sessions.

The client will be able to demonstrate the ability to ambulate with a platform walker independently from the bed to the chair to eat dinner within four treatment sessions.

The client will increase thumb opposition with strengthening exercises within three treatment sessions.

The client will utilize adaptive equipment for LE dressing independently within three treatment sessions.

LTG:

The client will demonstrate the ability to dress his lower body independently while seated at the edge of the bed within 6 treatment sessions.

The client will demonstrate the ability to functionally ambulate to the bathroom with a platform walker independently within 5 treatment sessions.

The client will demonstrate the ability to perform sponge bathing seated in the bathroom at the sink independently within six treatment sessions.

d. Current treatment methods/interventions (e.g. occupations, exercises, modalities, and where these methods would be used in the treatment process)

The client is being treated with preparatory, purposeful and occupation-based methods. He is given ice packs regularly to decrease swelling in his right hand. As a preparatory method he was given a series of stretches and activities for his right hand so that he will be able to oppose his thumb in the future. Bed mobility, transfers, and functional mobility are also implemented with this client as purposeful methods so that he will be able to regain strength as well as standing balance to be able to perform ADL tasks. The client is introduced to adaptive dressing techniques and tools, e.g. reacher and sock aid (occupation-based treatment). A big part of the treatment is education about precautions and compensatory techniques. The precautions are being repeated often as they are very important to the client's recovery. The client is never rushed and the treatment session goes at his own pace. Guidetti, Asaba, and Tham (2009) found out in their study about meaning of the context of self-care tasks that clients value the ability to take time on a task as they need to get used to their new or changed bodies. That way the clients are able to work on a task until they were able to finish it successfully instead of having to stop due to running out of time. Furthermore the clients need to relearn a task while their bodies continue to change. This was very true for the client in this case study. At first he had only minimal motion in his right hand and as therapy continued his motion was almost as good as in the other hand. His affected lower leg was secured by an external fixator at first and was then later on secured in a cast. This meant that he was unable to dress his lower body at first due to the fixator but was able to do so during later therapy sessions. The findings of the study also suggest that clients will thrive better if not given as many challenges at the beginning of therapy (Guidetti, Asaba, and Tham, 2009). At first using a sock aid and a reacher was only explained to the client. Once his physical status allowed for more he was given the task of using the equipment to dress himself. Waiting until the client was able to do the task enabled him to finish the task successfully.

e. Recommended treatment methods/ interventions

To start the treatment session of I would use the Canadian Occupational Performance Measure to figure out the client's progress. COPM helps the therapist and the client figure out areas of occupation that may be affected that one did not take in consideration at first (Colquhoun, Letts, Law, and MacDermoid, 2012). A lot of the treatment so far was limited to the client's bedside and was focused on lower body dressing therefore the COPM will be helpful to identify other problem areas the client may have. This would be part of the occupational profile- evaluation.

The client is able to use a sock aid and reacher for lower body dressing with minimal support. The goal is for him to be able to do it with only supervision. To be able to reach that goal it is important to work with the client on dynamic sitting balance. This goal can be reached with the purposeful method of leaning forward to pick up objects from the floor. This is purposeful as he has to lean forward as if he would to pull the pants over his feet or the sock over his foot. While one could just have him pull on his pants repeatedly this way the therapist is able to control the distance of the objects that the client has to pick up. It will also help him gain more control of the reacher with his non-dominant hand. Once he is allowed to use more force on his affected hand this would also be a good exercise for him to regain strength (pulling the trigger on the reacher repeatedly).

As a preparatory method the client should be presented with dumbbells to regain strength in his upper extremity. This is a preparatory method so that he is able to bear weight on his arms during functional mobility. He has been bound to a bed for a while and his body lost some of its strength during that time as well as due to the surgeries and anemia. The proper handling of the dumbbells would need to be explained to him as well as precautions that he needs to take. For example he would not be able to use the dumbbells with his affected UE until he has clearance from the attending physician. He should perform about 20 reps three times a day (biceps curls and triceps extension).

Another purposeful activity would be functional mobility. To be able to do any occupation-based task away from the bed, e.g. using the restroom or grooming tasks in the bathroom the client needs to be able to get there. The client should be motivated to start out just going from the bed to a chair next to the bed and then to a chair in the hallway the next day. Increasing the distance slowly will make the task seem less daunting to the client and he will be able to reach his goal of going to the restroom under supervision. A study conducted by John Hopkins Medical institution (2008) came to the results that patients on a ventilator in the ICU that are not able to exercise their bodies have a worse recovery rate than those that were able to. They found out that patients will suffer from neuromuscular weakness when they are not able to exercise their bodies. It can also lead to changes in heart function which would be a problem with the client described in this case study as he already suffers from atrial fibrillations. The researchers found out further that even healthy individuals will lose 4 to5 % of muscle strength after one week of bedrest (John Hopkins Medical Institution, 2008). Therefore functional mobility should further be included in the client’s treatment sessions.

7. Other services involved and referral recommendations (e.g. PT, SLP, social work, neuropsychology, pastoral care, teacher, wound care nurse, nurse) - briefly describe service of each discipline.

Physician: The client receives regular treatment from a physician who overlooks his medication and the healing process of the client’s leg.

Physical therapist: The physical therapist is concerned with the regain of motion and strength in the affected body part. She works on gait pattern with the client.

Social work/case manager (discharge/planning): A case manager will help the client find a rehab facility that is a good fit for him. They also take care of communicating with health insurances so that he is able to receive all the treatment that he needs to receive. The case manager also takes care and helps find solutions with any other concerns the client may have for example if he would have a dependent child at the house the case worker would contact social/youth services for the client.

Pastoral care: Pastoral care (spiritual care) is possible if the client is interested. Even if he is not very religious it will give him the chance of interaction with a person that is not directly related to taking care of his basic needs.

Nursing and wound care nurse: The nurses help the client with his basic needs. They help him get ready in the morning and at night, support him during toileting and give him his medications. They are also able to help him with transfers. A wound care nurse cleans his surgical sites and is also able to assess them to make sure that they won't get infected as well as re-bandaging them. The nurses will also report any change in the client’s status directly to the attending physicians as well as to the other professions on a need to know basis.

8. Psychological and social impact on therapeutic intervention.

The client is generally in good spirits. If he has a bad day he will normally tell the therapist right at the beginning that he wants to be left alone. Generally he can be convinced to partake a little bit in therapy even if it is only to show the progress of his thumb range of motion. His generally good attitude is good for his ability to progress in therapy. He is generally joking around with the therapist. He enjoys the social aspect of therapy. He has been in the hospital for a long time and without his family close by he has no one to talk to besides the hospital staff (except on the phone). It is likely that on the days that he does not feel up for therapy that his wife if she was there could motivate him to partake. The client did almost lose a leg and this can cause significant psychological trauma especially due to the fact that he does not remember the accident that well not did he ever had any illness or condition that tied him to a bed and made him dependent like he is now. He misses his wife a lot since they live out of state. She travels to see him as often as she can and also brings the dog along.

9. Discharge/transition plan – Consider aspects, such as needs, conditions that may affect outcomes, socioeconomic status, family and financial situation.

The client should be discharged into a rehabilitation center. He is still dependent in most of his ADLs and needs a lot of help that his wife cannot provide. The drive out of state is also something that his insurance would not pay as he cannot be transported in a regular car and the car ride would also not be good for his general constitution. He was supposed to retire in two months from the day of the accident so his financial status is hardly affected by this. He has worker’s compensation so his stay in a rehab facility is covered. During his stay in the facility the staff there will be able to intensify their training with him to work on proper transfer skills as well as evaluating his needs more in detail. They will also be able to identify any long-term needs or adjustments that need to be made to his house. The biggest focus of further treatment should be mobility. It will not only assure that the client can go home sooner rather than later but will also benefit his general health.

References

American Occupational Therapy Association. (2008) Occupational therapy practice and framework: Domain & process ( 2nd ed.).Bethesda, MD: AOTA Press

Bassini, L. & Patel, M. (2007). Pediatric hand therapy. In C.Cooper (Ed.) Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnosis of the upper extremity. St Louis, MO: Mosby, Inc.

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Colquhoun, H., Letts, L., Law, M., MacDermoid, J.(2012) . Administration of the Canadian occupational performance measure: Effect on practice. The Canadian Journal of occupational Therapy 79(2): 120-8.

Common Skeletal Injuries/Conditions (PDF document). Retrieved from Lecture Notes Online Web site: OT525S02WI14/skeletal_20injuries423.pdf

Cooper, C.(Ed.)(2007) Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnosis of the upper extremity. St Louis, MO: Mosby, Inc.

Deshaies, L.(2007). Burns. In C.Cooper (Ed.) Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnosis of the upper extremity. St Louis, MO: Mosby, Inc.

Guidetti,S., Asaba, E., & Tham, K. (May/June 2009). Meaning of context in recapturing self-

care after stroke or spinal cord injury. American Journal of Occupational Therapy 63 (3), 323-332. doi: 10.5014/ajot.63.3.323

Johns Hopkins Medical Institutions. (2008, October 16). Get Moving: New research shows

early mobility better than bed rest for ICU patients. ScienceDaily. Retrieved March 31, 2014 from releases/2008/10/081007172826.htm

Pendleton, H. & Schultz- Krohn, W. (2013). Pedretti's occupational therapy practice skills for physycal dysfunction (7th ed.). St. Louis, MO: Elsevier Mosby.

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