SCI

Name: Vanessa Li 6/24/2015

The OT Process Worksheet for Case study: Telephone Repairman Spinal Cord Injury C6
PROCESS STEPS
1 Referral
2 Screening
3 Evaluations
Functional problem list:
Acute Care
Eating, Dressing and Bed
Positioning are difficult to
perform due to lack of
wrist and hand function,
poor endurance and UE
strength.

Client will need a bowel

and bladder program due
total paralysis of trunk
and lack of sensation in
trunk and LE.
Tx/intervention Planning
(must identify at least 3
LTGs and 2 STGs for each
LTG to achieve minimal
requirements)

STANDARDIZED:

NON-STANDARDIZED:

Barthel Index (Functional

Eval)
Sollerman Hand Test
(Grip function)
Functional Independence
Measure (FIM)
ASIA

Medical Chart Review

Direct observation/Informal
Interview
Interest Checklist
Sensory Evaluation

FOR/MOP APPROPRIATE
FOR DX:
Biomechanical
(remedial/restorative)
Rehabilitative Treatment
Approach
MOHO

TYPICAL FUNCTIONAL LTGs: (7-14 days)

TYPICAL FUNCTIONAL STGs: (3-5 days)

1a. Patient will use universal cuff for

self- feeding with weighted utensil, plate
guard, lightweight plastic cup or mug
with less 50% spillage 2/3 meals a day.

Patient will be able to use adaptive

eating utensils (weighted spoon and
plate bumper) independently by the
time discharge.
Patient will be able to perform bed
position/mobility technique in order to
release pressure and prevent
decubitus ulcer.

1b. Patient will perform 10 rep with one

and half pound wrist weights while doing
an activity focusing on coordination to

Increase hand/wrist / shoulder

strength with the use of AROM and
PROM , splinting, and positioning.

improve ROM and strength and

endurance.
2a. Patient will increase sitting
progressively to from 30 minutes to 1.5
hours three times per day at upright
angle to improve endurance and trunk
stability to complete ADLs.
2b. Patient will maneuver self with no
more than moderate assistance into four
different bed mobility techniques within
eight to ten hours to prevent pressure
ulcers and improve strength and
coordination.
3a. Patient will utilize resting/dynamic
orthoses to prevent joint stiffness and
improve hand function to allow for
completion of ADLs.

Tx/intervention
Implementation

ACTIVE OCCUPATIONS:

- Feeding
- Bladder and bowel

3b. Patient will use his more functional

right hand to move his left wrist and
fingers through SROM (wrist extension
and finger flexion) three times a day to
improve ROM in both hands to prepare
for manual wheelchair mobility.
PURPOSEFUL ACTIVITIES:
PREPARATORY ACTIVITIES:

- Don/Doff of clothing on
the UE and LE.

- Heat pack to relax

muscle before PROM and

management

- Dressing
- Personal hygiene
- Functional mobility

- Eating a meal
- Playing a board game
- Petting and brushing his
dog

AROM exercises.

- Strengthening exercises
for upper extremities

- Deep breathing exercises

to increase endurance.

- Sanding a wood project

on an incline or with a
weighted block.

- Handling a stuff animal

6

Reevaluation Methods

Discharge Planning
(typical locations your
patients may be
discharged to)

Comments:

dog
Barthel Index (Functional Eval)
Sollerman Hand Test (Grip function)
Functional Independence Measure (FIM)
Client will be discharged to Inpatient subacute rehab, outpatient rehab, or home
health depending on clients progress and support. A home modification evaluation
is also recommended.