Unit 3: Inpatient Rehabilitation Setting (Clinical Case Studies) Flashcards
Sally: Polytrauma: Sally is a 40 year old mother of twin boys. She is also a school teacher and enjoys playing in a recreational softball team on the weekends. She was in a motor vehicle accident 3 weeks ago resulting in a right frontal lobe subdural hematoma requiring craniotomy, fracture and subsequent surgical fusion of her L4/L5 vertebra, and significant trauma to her left hand, which resulted in an amputation proximal to the carpal bones (wrist disarticulation). She has now transitioned to inpatient rehabilitation and presents for an OT evaluation.
-Classifications of UE amputation
-Surgical fusion of lumbar vertebrae
-Imaging of an acute subdural hematoma
Occupational Therapy after Polytrauma
• Polytrauma involves severe injuries to more than one organ structure.
• Requires a comprehensive approach to rehabilitation.
• Treatment is multifaceted and addresses the person
as a whole.
• Clinical implications for Sally: Pain management, Spinal precautions, Psychological impact of trauma
Psychological Impact of Trauma
-Post-traumatic Stress Disorder: A combination of symptoms occurring after a specific traumatic event. Including some or all of the following: Persistent reexperiencing of the traumatic event, Intrusive thoughts, Avoidance of stimuli associated with the injury, Physiologic arousal, Symptoms persisting for at least 30 days after the injury
-Patients who have experienced trauma may also be prone to depression, anxiety, fear of death, impulsive behavior, and reduced self-esteem.
-OTs play a role in helping the patient return to reinjury physical and emotional functioning.
-This includes psychological screening and addressing emotional well being and coping skills when indicated.
Sally: Polytrauma; Upon OT evaluation, she receives the following scores on the Functional Independence Measure
Treatment of Sally in Inpatient Rehabilitation
Based on the information provided, use worksheet 3.1 to complete the following activity:
- Write one LTG for Sally during her Inpatient Rehabilitation stay.
- Using the establish/restore approach from the OTPF, discuss 1 preparatory activity and 1 functional treatment activity you would plan for an OT session with Sally.
Michael: Heart Transplant
Michael is at 38 year old man with a history of congenital heart disease. He is a construction worker and also enjoys spending time with his aging parents, for whom he is the sole caretaker. Michael presents to inpatient rehabilitation after a heart transplant 14 days ago. There were no complications from the procedure but prolonged hospitalization left Michael weak and with a poor functional reserve.
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Occupational Therapy after Transplant
• Treatment often focuses on regaining function, optimizing endurance, improving strength to return to important life roles.
• May need vitals to be monitored during intensive therapy as well as more frequent lab draws as the body works to accept the organ(s).
• Clinical implications for Michael:
• Sternal Precautions
• Neutropenic Precautions
• Psychosocial implications of transplant
Activity Tolerance and Occupational Performance
• Activity tolerance refers to an individual’s ability to tolerate completing activities of daily living or meaningful tasks.
• Measuring activity tolerance:
• Borg rating of perceived exertion scale
• MET Chart
• Document how many minutes your patient is able to tolerate a specific activity
• Grade the activity by changing the demands, document the progression each session
Michael: Heart Transplant; Upon OT evaluation, she receives the following scores on the Functional Independence Measure.
Michael: Heart Transplant;
The evaluating OT also introduced the Borg Rate of Perceived Exertion (RPE) Scale to Michael and encouraged him to rank his RPE while he completed different functional tasks.
Based on the information provided, use worksheet 3.1 to complete the following activity: Treatment of Michael in Inpatient Rehabilitation
- Write 1 LTG for Michael during his inpatient rehabilitation stay.
- Using the create/promote approach from the OTPF, discuss 1 preparatory activity and 1 functional treatment activity you would plan for an OT session with Michael.
Bethany: Bilateral LE Amputation
Bethany is a 21 year old college student on the college swim team who was hospitalized with bacterial meningitis 5 weeks ago. Due to disease progression both of her lower extremities were amputated below the knee. She was critically ill for a few weeks in the hospital and developed hospital acquired weakness and failure to thrive due to poor PO intake. She presents for inpatient rehabilitation 4 weeks after surgery with her stitches removed and her residual limbs healing well. The evaluating OT notices moderate swelling in both lower extremities.
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Occupational Therapy after Amputation
-Residual limb care: Compression and shaping; Desensitization; Positioning; Prosthetic/ orthotic management
-Clinical implications for Bethany: Psychological aspects of limb loss; Limb loss can affect competence and satisfaction in life roles; Depression and anxiety
-OT can help by: Introducing patient to peer visitors who has had a similar amputation; Provide the patient with reference material on coping and adjusting
after amputation; Communicate and refer to other professionals as needed (psychologist or spiritual counselor); Equipment considerations for discharge home
Phases of Rehabilitation after Amputation
-Acute Post-Operative Care
-Pre-Prosthetic Training
Acute Post-Operative Care (Phases of Rehabilitation after Amputation)
• Hospital stay after amputation is typically 3-10 days post-op
• Medical management and stabilization
• Dressings, infection control, pain management
• Maintaining/improving ROM in the affected limb
Pre-Prosthetic Training (Phases of Rehabilitation after Amputation)
• Care team is focused on preparing residual limb for a prothesis: Skin care, muscle strength, pain reduction/ management and limb shaping.
• Management of edema
• Maintaining/improving ROM and preventing contracture
• Desensitization
• Evaluated by a prosthetist for limb readiness
• Pt should be communicating with a peer mentor to help with psychological adjustment and answer questions
• OT focus on optimizing independence
Prosthetic Prescription and Fabrication/ Community Integration (Phases of Rehabilitation after Amputation)
• Pt will meet with a prosthetist for prosthetic fitting and fabrication
• Continue to work with OT/PT on prosthetic use and community integration
Residual Limb Care
-Post operative care
-Phantom Limb Sensation/Pain
-Compression and shaping
-Desensitization
-Positioning & ROM
Post Operative Care (Residual Limb Care)
Provided immediately after surgery and addresses wound care, maintenance of skin integrity, join mobility, reduction of edema, prevention of scarring, and control of pain.
Phantom Limb Sensation/Pain (Residual Limb Care)
Patients often experience sensation in the missing limb.
• Limb percussion, ultrasound, transcutaneous electrical nerve simulation (TENS), acupuncture, psychotherapy, hypnotherapy, relaxation techniques, and mirror therapy.
Compression and Shaping (Residual Limb Care)
The goal is to shrink and shape the residual limb to that it is tapered a the distal end; this allows for optimal prosthetic fit.
Desensitization (Residual Limb Care)
Necessary to prepare the patient’s residual limb to tolerate touch and pressure.
• Wrapping, percussion (tapping, rubbing, or vibration), massage, weightbearing (unless contraindicated)
Positioning & ROM (Residual Limb Care)
It is important to maintain or increase range of motion and strength of the limb.
Bethany: BLE Amputations; Upon OT evaluation, she received the following scores on the Functional Independence Measure
