APA format
Case study of Harris
Harris: Spinal Cord Injury at T3, Complete
Harris is a 20-year-old African American male with a diagnosis of complete spinal cord injury at T3 and resultant paraplegia. Harris also has a diagnosis of a fractured right tibia and fibula and right proximal radial and ulna fractures. Harris was admitted to the rehabilitation hospital from the acute-care hospital where he stayed for 2k weeks after his accident.
Harris was in an automobile accident that resulted in his injuries. He was a passenger in the car and was struck from the right side by another car. Harris was pinned in the car for a short period of time and reports having no feeling in his legs immediately after the two cars collided. His friend, who was driving the car, was not seriously injured.
Harris lives with his fiancée, Marsha, on the 15th floor of a new apartment complex in the city, It is a small one-bedroom apartment, They intend to be married next spring. Harris is also planning on completing his baccalaureate degrec in computer science and has one semester left to finish, Harris works full-time for his brother’s plumbing business as a bookkeeper. During the little free time he has, he likes to travel with Marsha and golf with his friends. Harris had no funcional deficits before the accident.
Harris’ family is extremely supportive and visits daily. His brother Jeff calls frequent|y and his mother makes all his favorite meals, which she brings in for the nurses as well as Harris. Harris’ father is not well and cannot visit as often due to respiratory distress, but teleshones his son regularly. Marsha, who is a dental hygienist, has taken time off work to be with Harris every day at the hospital.
Harris is admitted to the rehabilitation hospital with the goal of returning home. He is eager to get started and tells the admission nurse “he more therapy, the better.” Harris will be evaluated by PT, OT, nursing, social work, and the physiatrist.
Occupational Therapy Evaluation
Upon evaluation, Harris is talkative and motivated. He is in a wheelchair with lateral supports. His right LE is in a full-arm cast and his right LE is in a cast from the toes distal to the knee. Harris says he is right-handed. When asked how he has been feeling since the accident, his reply is “fine.” When the question is rephrased as to his emotional state, his response is the same.
Harris has no cognitive, perceptual, visual, or hearing deficits. He has no sensation in either LE and reports no sensation in his buttocks as well., His LE sensation is intact, as is the sensation in his superior trunk region. His sensation is impaired in his inferior trunk region. Harris’ low back area cannot be assessed during the evaluation due to his position in the chair.
Harris has no AROM in the LEs. His motion is intact in the left UE and cervical area. His right LE cannot be fully assessed due to the cast. Motion in his right digits is normal given the limitations of the cast. His left UE has normal strength, right UE is not fully assessed, but Harris can lift the cast up over his head.
Harris has no complaints of pain except for stiffness in his neck. He has some light edema in the right digits at the MCP to DIP joints but no cyanosis. He has multiple bruises and abrasions over his body that nursing is monitoring.
Harris’ sitting balance is poor to fair, and he is unable to sit up independently without minimal assistance. He does attempt to correct himself when leaning but lacks the strength to maintain upright posture without external assistance. He is independent in sitting with the lateral supports in the wheelchair.
Harris uses a sliding board with moderate assistance to transfer from surface to surface. He is non-ambulatory and is non-weight-bearing on the right leg. Harris requires ocasional assistance to propel himself in a wheelchair because of his inability to use his right arm. He performs bathing tasks ably and can wash his face, hands, chest, and peri-area independently. He requires total assistance for back, buttocks, and legs. He requires maximum assistance for dressing himself. Harris reports feeding himself without help although “it’s messy sometimes.” Harris has a catheter for urination and had been incontinent of bowel since the accident. His admission Functional Independence Measure (FIM) scores were in the 3 to 4 range for UE tables and 1l range for LE tables.
Assignment Objectives:
· The student will identify and demonstrate (as applicable) role and participation in the Occupational Therapy process (referral, screening, evaluation, treatment planning, intervention, reevaluation and discharge planning)
· The student will determine and select the model of practice/frame of reference that would best guide the treatment of the identified impairments.
· The student will demonstrate proficiency in applying OT treatment techniques and practices to a case study that will be assigned to them.
· The student will create a problem list, list of strengths, long-term goals, and short-term goals.
· The student will demonstrate treatment session which will be described in an intervention note.
· After the treatment session, the student will identify opportunities to recommend to the occupational therapist the need for referring client for reevaluation, discharge planning and additional evaluation for other services and/or professional(s).
Procedure:
· The student will be assigned a case study with an array of physical dysfunctions.
· Student will complete an analysis based on a structure and guideline that requires information in regards to: Problems, strengths of the client, long-term and short-term goals for treatment.
· Student will develop two treatment sessions applying techniques, strategies and practices
· Student will demonstrate by role play, one treatment session.
· Student will write an intervention/treatment note accordingly.
