South Eastern Rehabilitation Case Study

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Client Information: Name: Daniel Lodge * Facility: South Eastern Rehabilitation* Age: 18 years old Gender: Male Occupation: Apprentice Fire Sprinkler fitter Personal Interests: Motorbike riding, Four-wheel driving, going to car events and hanging out with family and friends. Diagnosis: Daniel was riding motorbike at approx. 40 km/h when he hit a stump and came off of his motorbike. Patient (pt) does not remember what happened just remembers that he had no feeling in his legs once re gaining consciousness. Pt has been diagnosed with a spinal cord injury (SCI) complete T4 ASIA A paraplegia. The lower the SCI is, the more trunk muscles will work, this helps with balancing and moving positions with ease. (Spinal Hub, 2014). Personal…show more content…
Assessments: Assessments tools used within Daniels rehabilitation stay are the initial assessment and a home assessment. - Initial Assessment: Allowed the Occupational Therapist (OT) to explain what they were there to help Daniel with, establish a rehabilitation plan and goals towards d/c. Pt provided information on what they would like to get out of OT and what goals they would like to work on. It also allowed the OT to suggest any other assessments Daniel may need whilst he was in rehabilitation. The initial assessment is not a standardised assessment. - Home Assessment: Are also not standardised, this is going to make it clear to both Daniel and his family as to what his needs are for when he goes home, the pt will need to be able to access the house, this may mean home modifications may need to be completed, pt has completed a TAC and waiting the outcome. If TAC approves of the pt’s claim this will help with any modifications needed as the TAC will fund part of the modifications if not…show more content…
Dress independently, Daniel is able to dress his upper body with assistance from the hi-lo bed he uses and he requires some supervision currently, he wishes to be completely independent while dressing and to stop relying on nurses to help him. Therapist to organise dressing sessions until pt thinks he no longer needs to be supervised. Encourage Daniel to practice in his own time with assistance or supervision of a nurse or a family member. 3. Encourage Daniel to change over his licence from a Western Australian licence to a Victorian licence, inpatient therapist to provide a brief overview of the return to drive process. OT to write a referral to outpatient OT driving assessor. 4. Complete a home assessment to decide on any home modifications needed such as ramps, bathroom and bedroom access, speak to a local community OT in regards to d/c return to community living plan (Noreau, 2013) 5. Complete day leave pass for Daniel to attend events coming up such as sisters birthday and social events, transfer assessment and pressure training for inpatient OT to organise. To build up sitting tolerance to travel home. 6. Pt to attend cooking group to start retraining for some

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