Case study of harris

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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.

2


Case Study


Lab Assignment

Name:_____________________

Date: _____________________

Course: OTA 104/105: Activity Analysis

Course objective(s):

UNIT SEVEN: Analyzing Human Motion in Daily Activity

Upon successful completion of this unit on written and practical examination, the student will:

Analyze various case examples by:

a. Identifying physical performance impairments during an occupation.

b. Selecting appropriate tests to assess the indentified physical performance deficits.

c. Determining and justifying in written form which model of practice/frame of reference would best guide the treatment of the identified impairments.

d. Implementing the selected frame of reference/model of practice in correcting, or compensating, for the identified impairments.

e. Role-playing a treatment session based on student analysis

Curriculum thread(s) addressed:

·
Occupation Centered Practice

·
Role Acquisition

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.

Written assignment:


Poor (1)


Fair (2
)


Good (3)


Excellent (4)


Score

Determine and select model of practice/frame of reference to best guide the treatment of the identified impairments.

Unable to determine appropriate Application of model of practice/frame of reference

Additional questions arise. Difficult to follow, yet selected practice/frame of reference is present.

Application of model of practice/frame of reference requires additional clarification

Application of model of practice/frame of reference is best suited

Use of proper OTPF terminology and grammar

Use of inaccurate terminology or grammar on more than 8 occasions.

Use of inaccurate terminology or grammar on no more than 6 occasions.

Correct use; with use of inaccurate terminology or grammar on no more than 4 occasions.

Correct use; with use of inaccurate terminology or grammar on no more than 2 occasions.

Summary of primary and secondary medical diagnoses: signs, symptoms, prognosis, prevalence

Did not identify. Clarification needed

Missing 50% of data

Missing 25% of data

All relevant information provided

Developed a prioritized OT Problem list.

Explained justification of prioritization using the OTPF.

Not addressed or information not relevant.

Only two problems are OT relevant and student requires additional clarification about how practice framework is utilized to prioritize problem list.

Most problems are OT related and can be addressed by therapist. Most problems prioritized and justified with fair use of practice framework.

Problem list is accurate and prioritized considering patient specific diagnosis, needs, and wants. Utilized and explained clearly application of practice framework to problem list.

Identified all problems of the patient accurately

Did not identify problems accurately on 5-6 occasions

Did not identify problems accurately on 3-4 occasions

Identified all problems, but did not identify problems accurately on 1-2 occasions

Identified all problems accurately

Identified accurately and correctly all strengths and opportunities of the patient in the case study

Did not identify accurately and correctly all strengths and opportunities of the patient in the case study on 5-6 occasions

Did not identify accurately and correctly all strengths and opportunities of the patient in the case study on 3-4 occasions

Identified accurately and correctly mostly, but failed to identify accurately and correctly on 1-2 occasions

Identified accurately and correctly all strengths and opportunities of the patient in the case study

Completed all long term goals accurately and correctly meeting all the criteria utilizing FEAST or other documented method

Did not complete long term goals accurately and correctly meeting all criteria on 5-6 occasions

Did not complete long term goals accurately and correctly meeting all criteria on 3-4 occasions

Completed long term goals accurately and correctly meeting most criteria, but missing on 1-2 occasions

Completed all long term goals accurately and correctly meeting all the criteria

Completed all short term goals as applicable

Did not complete 5-6 short term goals

Did not complete 3-4 short term goals

Good, but missed the completion of 1-2 short term goals

Completed all short term goals as applicable

Methods/Interventions

Listed methods used to treat patient in a comprehensive list to be used as treatment plan guide. Indicate FOR (s) for treatment session.

Information provided is vague.

Methodology is not comprehensive and lacking information.

Good, but additional clarification needed.

Comprehensive list of methods that will be used in intervention. Sound, research based methodology is evident FOR (s) is indicated.

Rationale/Justification

Describes the rationale behind above methods and gives reason why this will work (justification)

Unacceptableperformance and clinical reasoning

Rationale is missing or not sound on several methods

Good, but rationale is incomplete or not sound on some methods

Sound rationale given for each method. Comprehensive.

Created and developed two treatment sessions utilizing time management skills and progression in the treatment continuum

Did not create and develop treatment sessions accurately and correctly

Creation and development treatment of sessions require additional work. Uses clinical reasoning skills for 50% of session

Good overall. Additional clarification required. Most ideas are good and uses clinical reasoning skills for 75% of session

Created and developed two treatment sessions accurately and correctly, meeting the criteria

Treatment session:

Description of main medical diagnosis, and any precautions.

Brief description of patient’s status and goals.

Too long or too short of expected length of time

Part of the treatment session is appropriate and addresses goals.

Most of treatment session is appropriate & addresses goals.

Medical and diagnoses information covered. Important precautions mentioned. Brief discussion of patient’s status and goals-

Uses and prepares equipment in the lab.

Last minute preparation with materials.

Creativity shown.

Creativity, flexibility. Demonstrates how activity can be graded.

Overview of treatments selected and why they are appropriate for this patient is indicated.

Address Q & A.

Unable to answer questions from instructor/ students related to rational or activity analysis or interventions.

Nervous, but attempts to answer questions at the end of treatment session.

Answers questions easily and somewhat accuratel
y at the end of treatment session
.

Student is able to explain and answer all questions at the end of treatment session. Shows how activities can be graded up or down. Rational is complete

Shows creativity. At the end of the treatment session, identifies opportunity 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).

Written activity analysis for each activity.

Vague, not well elaborated, does not address value or meaning of activity. Explanation will not contribute to analysis.

Many questions arise. Data provided is acceptable, but more effort is required.

Data provided that may assist in identifying value of activity for use in treatment requires minimal additional clarification.

Well discussed, provides meaningful relevant data that may assist in identifying value of activity for use in treatment

Shows progression from adjunctive to purposeful as appropriate.

Rationale and explanation of interventions.

Unacceptable. More creativity and justification required.

Many questions arise. Rationale and explanation of interventions requires additional focus and concentration

Progression from adjunctive to purposeful requires additional thought process.

Rationale and explanation of interventions require additional work but can be followed. Some questions arise.

Progression from adjunctive to purposeful as appropriate.

Rationale and explanation of interventions is clearly identified.

Shows priority as related to discharge plans as appropriate.

Vague and not well elaborated.

Priority as related to discharge plans is not as evident. Many questions arise

Priority as related to discharge plans requires additional clarification

Priority as related to discharge plans as appropriate.

After treatment session, identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s).

Unacceptable. Evidence of knowledge and understanding is not apparent

Identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s) is articulated, however, many questions arise

Identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s) is articulated., however, knowledge and understanding is not as apparent. Minimal clarification to increase knowledge and understanding required.

Identification of

opportunity to

recommend to the occupational therapist the need for referring client for reevaluation and additional evaluation for other services and/or professional (s) clearly articulated. Knowledge and understanding is evident.

Evidence based treatment: AJOT or other researched based articles are used to support one intervention.

Copies of article included with paper.

No evidence of article or

more than 25% of the information is not accurately transcribed.

Selection of articles are not highly relevant to case study/or is/are insufficient.

Another article is recommended

Selected article supports specified intervention, but rationale requires additional clarification

Selected article addresses specified intervention with supporting rationale provided

Treatment Note:

Completed all sections of the intervention/treatment note utilizing all the necessary criteria

Unacceptable contribution. Requires remediation in note writing.

Additional clarification is required. Moderate corrections required

Minimal corrections required, however, able to follow

Completed all sections of the intervention/treatment note

Subjective

Objective

Assessment


Plan

Comment:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Score:

Paper: Your score was _____________

Treatment session: Your score was _____________

Treatment note: Your score was _____________

The total score to accumulate is “56”. Your score was _____________ with a

percentage of _______________


ACOTE Standards for an Accredited Educational Program for the Occupational Therapy Assistant:

(B.2.11. , B.3.2., B.4.1., B.4.4., B.4.96., B.5.4.92., & B.5.84.10)



Revised 12/08/15 JM; revised 04/2029/2016 2020 JM

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