This presentation is by Laura Holman, Taylor Vento and Molly Alma’s. Judy is a 54-year-old wife and mother who sustained a traumatic brain injury following a motor vehicle accident. Judy’s injury was a closed diffused brain injury caused by the force of the impact. As a result, she will be an inpatient rehab for three weeks.
Traumatic brain injury is defined as: damage to brain tissue caused by an external mechanical force, with resultant loss of consciousness and post traumatic amnesia. Skull fracture or objected neurologic findings that can be attributed to the traumatic event on the basis of radiologic findings of physical or mental status examination.
More specifically Jody sustained a closed diffused traumatic brain injury. Closed brain injury is usually result from a direct or indirect impact without penetration of the brain tissue. Diffuse brain injuries most commonly occur in motor vehicle accidents, like in Judy’s case.
Where there is rapid movement of the head. The below link is a good source to better understanding the brain and how traumatic brain injury affects it. Typically, when a patient presents with a brain injury the Rancho Los Amigos levels of cognitive functioning scale is used to categorize the patient’s level of cognitive function, via behavioral observations. This scale ranges from levels one to ten with one being the most severe. State characterized by no response to visual verbal tactile auditory and noxious stimuli and 10 being the highest level characterized by purposeful inappropriate behavior. As well as modified independence.
The first three levels describe the patient’s response to stimuli in the environment when emerging from a coma. This scale is very helpful in medical practice because it allows clinicians to better communicate amongst themselves. Then with the family about a patient’s level of cognitive function and contributes to the development of appropriate rehabilitation strategies.
Judy is a Rancho level five six and those had improved from inappropriate to appropriate responses but remains confused.
When at level five Judy is able to respond to simple commands but is more confused with complex commands, she can grossly attend to the environment but is highly distractible. At level six, Judy begins to show signs of understanding and demonstrating more goal directed behavior but continues to require external cues to stay on task. She also begins to become more functional to complete her common daily activities. In the past Judy has been treated for chronic back pain and anxiety.
An avid smoker prior to admission to the hospital she was independent in all ADL’s leisure activities and community mobility. Judy takes several different forms of medication including Ritalin to address her distractibility in short attention span.
Prevacid to treat her stomach condition, singularities prevent and control her asthma and also coumadin to prevent deep vein thrombosis. Additionally, Judy takes a daily multivitamin and has no reported allergies.
Judy lives at home with her husband and her adult children one son and one daughter, live close by. She lives in a two-story home that has five steps leading to its entrance. She was not employed prior to admission but volunteered regularly at the local hospital. When she wasn’t participating in volunteer work she enjoys shopping and engaging in cognitive stimulation activities such as playing cribbage and Sudoku. Judy was an optimistic individual prior to her injury and is thus currently very motivated to recover and get back to doing the things she both needs and wants to do.
The evaluation process begins with an evaluation that focuses on finding out what Judy wants and needs to do and identifying the factors that act as supports or barriers to health and participation. We started with a vision and visual perception screening before beginning additional assessments. No visual or visual feeling deficits were found in Judy. The main assessments we utilize for Judy COPM, Goniometer for range of motion a dynamometer for strength. The Ashworth scale the FEM and the KELS.
The COPM is the first major assessment we performed on duty the COPM we’re Canadian occupational performance measure is designed for use by occupational therapists to detect change and a client’s perception of occupational performance over time. The COPM is client centered and is intended for use as an outcome measure. Meaning it should be administered at the beginning of occupational therapy services and again at appropriate intervals afterwards.
The COPM identifies problem areas in occupational performance provides a rating of the client’s priorities evaluates performance and satisfaction relative to identify problem areas and measures changes in a client’s perception of his or her occupational performance. Over the course of occupational therapy intervention through the COPM we identified the most important occupational performance issues for duty these occupational performance issues included self-care difficulties with bathing dressing and being able to brush your teeth.
Being able to volunteer at church which is a very important part of Judy’s routine and concerns with being able to play cribbage. The interview resulted in identifying an important goal for Judy, to be able to return to her volunteer work at her local church. Here is an example of the Canadian occupational performance measure form that was filled out for Judy. We used a goniometer to evaluate Judy’s range of measure this assessment found that Judy had significantly decreased range of motion in her right upper extremity that is not within functional limits.
We also discovered that passive range of motion is painful in her right shoulder and wrist. We then used a dynamometer to assess Judy’s hand grip strength which is important for her activities of daily living and functional mobility. The results of this test found decreased strength and Judy’s right upper extremity when compared to her left extremities. The Ashworth scale was designed to quantify the degree of hyper tennis it has been found to be a reliable scale for assessing spasticity.
Please watch the video below to watch and hear more about Judy.