Case Study Of HarrisHarris Spinal Cord Injury At T3 Complete

Case Study Of Harrisharris Spinal Cord Injury At T3 Comple

Apa Formatcase Study Of Harrisharris Spinal Cord Injury At T3 Comple

APA format 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 2 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 degree 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 functional deficits before the accident. Harris' family is extremely supportive and visits daily. His brother Jeff calls frequently 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 telephones 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 occasional 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.

Paper For Above instruction

In this case study, Harris Harris, a 20-year-old male with a complete spinal cord injury at T3, exemplifies the complexities involved in rehabilitation following traumatic spinal injuries. His case underscores the importance of a comprehensive occupational therapy (OT) approach that addresses both physical impairments and psychosocial factors to facilitate optimal recovery and reintegration into daily life.

Introduction

Spinal cord injuries (SCI) often result in profound functional deficits, significantly impacting individuals’ independence and quality of life. The need for individualized treatment planning is critical, considering the specific level and completeness of injury, baseline functional status, and personal goals. Harris’s case, involving a T3 complete injury, presents unique challenges and opportunities for targeted OT interventions aimed at maximizing remaining functional capabilities, promoting independence, and addressing psychosocial needs.

The Occupational Therapy Process

The OT process begins with comprehensive referral and screening, followed by detailed evaluation. Recognizing Harris’s motivation and support system, the therapist can tailor interventions aligned with his goals of returning home, completing his degree, and maintaining social and recreational activities. Initial assessment reveals significant impairments, including paraplegia, impaired sensation below the T3 level, poor sitting balance, and dependence in activities of daily living (ADLs).

The primary focus of therapy involves improving sitting balance, increasing independence in transfers and self-care, and adapting to wheelchair use. Additionally, addressing edema, managing skin integrity, and preventing secondary complications are vital. The therapist must also evaluate Harris’s psychological well-being, motivation, and social support, which are crucial for adherence to therapeutic activities.

Choosing the Model of Practice

The International Classification of Functioning, Disability and Health (ICF) model provides a comprehensive framework for Harris’s rehabilitation. This model emphasizes the interaction of body functions and structures with activity limitations and participation restrictions, considering personal and environmental factors. Implementing the ICF framework facilitates holistic treatment planning, integrating physical, emotional, and environmental considerations to promote positive outcomes.

Treatment Planning and Intervention Strategies

Based on the evaluation, targeted interventions focus on improving wheelchair mobility, developing upper limb strength, and teaching adaptive techniques for daily activities. Techniques such as task-specific training, motor learning principles, and compensatory strategies are employed. For instance, strengthening residual upper extremities and facilitating independence in dressing with adaptive tools align with Harris’s goals. Use of assistive devices, environmental modifications (e.g., accessible bathroom fixtures), and promoting self-management are integral components.

Psychosocial support is also critical; counseling and peer support groups can enhance motivation and emotional resilience. The therapist could incorporate education on skin care, pressure sore prevention, and management of edema, improving overall health status.

Development of Short-term and Long-term Goals

Long-term goals include Harris achieving maximum independence in self-care, transfers, and wheelchair mobility, and returning effectively to his community and academic pursuits. Short-term objectives focus on improving sitting stability, enhancing upper limb strength, and establishing consistent skin and edema management routines. Specific measurable goals guide the progression of therapy and facilitate ongoing evaluation.

Implementing Treatment Sessions

Two treatment sessions demonstrate the application of therapy techniques. The first session emphasizes positioning, edema control, and adaptive dressing strategies. The second session focuses on wheelchair propulsion techniques, upper limb strengthening exercises, and patient education on skin integrity and pressure sore prevention. Each session is documented via detailed intervention notes, emphasizing client participation, progress, and ongoing needs.

Reevaluation and Discharge Planning

Periodic reevaluation ensures therapy remains aligned with Harris’s evolving capabilities and goals. Discharge planning involves coordination with home health services, community resources, and assistive technology providers. Recommendations include environmental modifications at home, caregiver training, and structured follow-up therapies to sustain gains and prevent secondary complications.

Conclusion

Harris’s case highlights the critical role of occupational therapy in managing SCI-related impairments. A holistic, client-centered approach based on the ICF model facilitates functional recovery and promotes quality of life. Future research should continue to refine intervention strategies, incorporating advances in assistive technology and neurorehabilitation to optimize outcomes for individuals with SCI.

References

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