Physical Rehab Case Study
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School
University of Toledo *
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Course
4740
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
8
Uploaded by CorporalLlama2154
Lydia Holland
College of Health and Human Services, The University of Toledo
Professor Wendy Maran
Case Study #1 - Physical Rehabilitation
November 12, 2023
Definitions:
a.
A Left Cerebrovascular Accident(CVA) is also known as a stroke. A left CVA can
cause right hemiplegia, language deficits, and slow and cautious behavior style.
-
Symptoms of a CVA may include:
-
Trouble walking
-
Dizziness
-
loss of balance
-
sudden severe headache
-
Nausea
-
Fever
-
Vomiting
-
brief loss of consciousness.
-
Hypertension (High Blood Pressure) may have played a role in the CVA due to
the strain that high blood pressure has on the blood vessels in the body. According
to the Stroke Foundation “High blood pressure can lead to a stroke in several
ways: It damages blood vessel walls and makes them weaker. It can speed up
common forms of heart disease. It can cause blood clots or plaques to break off
artery walls and block a brain artery. “
b.
Expressive Aphasia: Expressive Aphasia can cause a person to seem like they lack
emotion. They are unable to move their facial features to show emotions.
Symptoms:
-
Speak in incomplete sentences
-
Sentences do not make sense
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Unrecognizable words or expressions
-
Difficulty showing expressions
1.
Assessment
The most appropriate assessment to be given to Josie would be the CERT assessment. Taking
Josie's leisure activities into consideration I believe that CERT PD is the best option for her. She
enjoys playing the piano, and doing needlework, crocheting, knitting and playing cards, all of
these activities require both gross and fine motor skills, and cognition, these are just 3 examples
of measurements assessed in the CERT-PD assessment.
2.
Factors for Treatment Plan
Positive:
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No Steps to enter apartment
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No architectural Barriers
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Shower has built in seat and safety
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Daughter in law help with grocery shopping and cleaning
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Participates in various crafting activities
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Ability to communicate needs using pantomime or pictures
Deficits:
-
Not much independent with daily activities
-
Hypertension
-
Osteoporosis
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-
Poor balance
-
Expressive aphasia
-
Impaired communication
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Requires a wheelchair with max assist
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Needs assistance with ADLs
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Lack of ROM on R UE
3.
Interventions and ICF Codes
1.
Balance (ICF d415 Maintaining a Body Position)
2.
Dexterity (ICF d440 Fine Hand Use)
3.
Music for Smoothness of Movements (ICF b137 Psychomotor Functions)
4.
Outcomes for ICF Core Codes
1.
Balance (ICF d415 Maintaining a Body Position). Josie is expected to work on
balance while in care. The outcome expected from this code is that she will be
able to maintain an upright position safely, without a fall.stumble.
2.
Dexterity (ICF d440 Fine Hand Use). Josie enjoys a variety of needlework crafts.
Due to her CVA she has lost some ROM and ability for some ADLs. By working
on dexterity she will be able to participate in more activities that require fine hand
use.
3.
Music for Smoothness of Movements (ICF b137 Psychomotor Functions). Josie
wants to return to playing the piano. Piano playing can help not only with fine
motor skills, but also the use of music in TR can help with psychomotor
functions.
5.
Goals and Objectives
Target problem
Goal
Objective
Intervention(s)
ICF code(s)
Balance
To remain in
an upright
position for 5
minutes
without
stumbling or
falling
Pt will be able
to remain in an
upright position
for at least 5
minutes without
falling within 2
weeks of
treatment.
Maintaining a
Body Position
ICF d415
Dexterity
Pt will be able
to utilize a
stitch board to
simulate
needlework
activity
Pt will use a
stitch board to
simulate
needleworking
projects.
Through this
intervention pt
will be
improving fine
hand use by
having to pass
string through
small holes to
simulate
Fine Hand Use
ICF d440
needleworking.
Pt will be able
to move on to
needleworking
projects by
week 2 of
treatment
Smoothness of
Movements
Pt will utilize
musical talents
to help with
fine motor
skills, and
psychomotor
skills
Pt will practice
the piano 2
times a day for
2 weeks to help
with fine motor
and
psychomotor
functions to
help improve
memory,
emotional state.
Psychomotor
Functions
ICF b137
6.
Action plan for the client/patient involvement
The Action plan is the major focus of any treatment plan and specifies the programs in
which the client/patient will be involved. The chosen programs should match the problem
list and incorporate the potential for the client/patient to meet their goals and objectives.
The action plan should include recommendations of groups.
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Create three (3) or more actions set up as follows.
Enroll client in Activity exploration (leisure resource focus) MWF 2:00-3:00 pm from 10/10-
10/20. Focus on: community resources, costs and benefits of chosen resources; developing
leisure participation plan.
1.
Enroll client in Activity exploration with a Balance focus MWF 2:00-3:00 pm from
10/10-10/20. Focus on: Stability, stepping forward,up,and down, rhythm of walking,
balance. Client will be provided during sessions with a piano rug. Client will be
instructed on what keys to step onto, how fast or slow to step, how big of a step to take,
and in what direction she is to step. Utilizing the piano rug will provide her the
opportunity to participate in her leisure interest of playing the piano while practicing
balance and maintaining an upright position.
2.
Enroll client in Activity exploration with a dexterity focus MWF 3:00-4:00 pm from
10/10-10/20. Focus on: fine motor skills, use of hands, grip strength. Client will be
provided each session with a stitch board. She will use a yarn needle, and yarn to stitch
different patterns into the stitch board each session. Utilizing the stitch board will help
with her fine motor skills and grip strength as well as help her practice to get back into
needleworking.
3.
Enroll client in Activity exploration with a Smoothness of Movements focus MWF 4:00-
5:00 pm 10/10-10/20. Focus on: motor skills, emotional regulation through music, and
Psychomotor Functions. Client will utilize a keyboard during sessions and practice music
that will be provided, or simply pressing on different keys when instructed by CTRS. By
following the music provided, or by following the commands given by the the CTRS this
allows for the client to have to connect her brain and movement together to complete the
task.